Exhibit XII Bed Hold.pdf

This document is a Congregate Care Bed Hold Authorization form issued by the Arizona Department of Child Safety (DCS). The form is designed for contractors providing congregate care services to request a temporary hold on a child's bed placement under specific circumstances. The form allows for bed holds up to 7 days with approval from the Statewide Placement Program Manager, and up to 14 days with the Statewide Placement Program Administrator's signature.

The form provides multiple reasons for bed hold requests, including AWOL (absent without leave), detention, extended visit (waiting for CPC), hospitalization, or other specified reasons. The contractor must complete client information including the child's name, personal identification number (PID), facility name, and the number of days requested for the bed hold. The form requires confirmation of specific actions (such as calls to the hotline and police department for AWOL cases) and includes signature lines for the contractor and the Statewide Placement Program Manager/Administrator. Completed forms can be submitted electronically to BedHold@azdcs.gov.