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 bed hold for a child who is temporarily absent from the care facility due to various reasons such as being AWOL, detention, extended visit, or hospitalization.

The form allows contractors to request bed holds for up to 7 days with approval from the Statewide Placement Program Manager, or up to 14 days with additional authorization from the Statewide Placement Program Administrator. The document provides fields to capture critical information including the child's name, Personal Identification (PID) number, facility name, actual start and end dates of the bed hold, and the specific reason for the request. Completed forms can be submitted electronically to BedHold@azdcs.gov, and require signatures from both the contractor and the Statewide Placement Program Manager/Administrator.