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 to request a bed hold for a child in their care under specific circumstances such as AWOL, detention, extended visit, hospitalization, or other reasons. The form allows for bed holds to be approved by the Statewide Placement Program Manager (up to 7 days) or the Statewide Placement Program Administrator (up to 14 days).

The form requires detailed information about the child, including their name, Personal Identification (PID) number, and the specific dates and duration of the requested bed hold. Contractors must provide a reason for the request and can submit the completed form via email to BedHold@azdcs.gov or through a digital submit button. The document includes signature lines for the contractor and the Statewide Placement Program Manager/Administrator to authorize the bed hold, ensuring proper documentation and approval for maintaining a child's placement during temporary absences or special circumstances.