BOP Program Statement 6027.03 § 4

PROTOCOLS

Granting authorities may grant privileges, practice agreements, and protocols to approved health

care providers based on appropriate review of their knowledge, skills, performance, completion

of orientation, and the overall peer review process, as applicable. They must also verify, through

the NPDB query, no adverse actions are reported that would restrict the applicant’s ability to

practice in any state a licensure is held.

a. Governing Body Representation. The Bureau, through the Assistant Director, HSD, assigns

the Medical Director as the privileging granting authority.

b. Bureau-Wide Coverage. Credentials within the Bureau fall under federal supremacy.

Specific health care providers will have and be granted privileges, practice agreements, or

protocols that will be valid at all Bureau facilities regardless of state affiliation. In addition, all

other Bureau health care providers who are credentialed to provide patient care will also have

bureau wide credentials. Site-specific privileges, practice agreements, protocols, and other

credentials are not required. However, those working under protocols should become familiar

with all local, site-specific, protocols as appropriate. Temporary duty (TDY) staff credentials can

be verified via memorandum or other electronic methods.

Federal supremacy allows contractors to work in a federal facility, even if the facility is in a state

where the contractor is not licensed; however, each institution must ensure a credential file is

current and maintained and that services provided fall within the approved statement of work.

Health Service Administrators and other staff in non-clinical positions can remain clinically

active at the institution during emergencies, and periods of critical staffing shortages, but only if

they have current credentials, pertinent to their professions, prior to performing any clinical

duties. Institutional specific situations can be reviewed on a case-by-case basis.

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c. Granting Authority. Authority to grant clinical privileges, practice agreements, and

protocols is defined as follows:

 The Bureau Medical Director or the acting designee, is the privilege granting authority

for:

 Regional Medical Directors

 National Chief Dentist

 National Chief Psychiatrist

 Central Office Social Workers

 Federal Bureau Telehealth Staff

 Clinical Specialty Consultants

 National Chief Pharmacist

 Other Central Office health care providers (e.g., Central Office Pharmacists,

Population Health, Addiction Medicine, Transitional Care) identified by the Bureau

Medical Director

 The Bureau Chief, Health Programs or the acting designee, is the privilege granting

authority for:

 MRC CDs

 The Bureau National Chief Dentist or the acting designee, is the privilege granting

authority for:

 Regional Chief Dentists

 National Clinical Specialists, including prosthodontists and periodontists

 The Bureau National Chief Psychiatrist or the acting designee, is the privilege granting

authority for:

 National Telepsychiatry Providers

 The Regional Medical Director or acting designee, is the privilege granting authority for:

 Regional Physicians and other health care providers

 Institution CDs within the region, other than MRCs

 Acting Institution CDs within the region

 The Regional Chief Dentist or acting designee, is the privilege granting authority for:

 Regional Dentists within the region

 Institution CDOs within the region

 The Institution CD or acting designee, is the privilege granting authority for:

 Bureau staff health care providers at the institution

 Contract staff health care providers who provide care onsite at the institution

 The Institution CDO or acting designee, is the privilege granting authority for:

 Bureau staff dental health care providers at the institution

 Contract staff dental health care providers who provide care onsite at the institution

d. Vacancies of Local Privilege Granting Authorities.

 Vacancies of institution CDs.

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 The Regional Medical Director will assign an Acting CD and notify the Institution

Warden and HSA. The notification will include an effective date and an end date not

to exceed the appointment of a new CD or the current expiration date of the Acting

CDs privileges.

 The Regional Medical Director will be the Acting CD when a vacancy occurs in the

CD role at an institution within the region, unless delegated by memorandum to

another physician. The acting delegation memorandum needs to be placed in the

physician’s credential file who is assuming the acting role.

 The physician assuming the Acting CD role is required to review all current

privileges, practice agreements, and protocols they are the privilege granting authority

for, to ensure they are current, and they concur with the provisions afforded within

them. This review will take place within 60 days of the Acting CDs appointment. The

Acting CD will sign a memorandum to be placed in the credential file of each health

care provider attesting to the review. The 60-day time frame does not give any

providers additional time for their renewals of privileges, practice agreements, or

protocols. They are still required to be renewed prior to their expiration date.

 Once a CD position is hired, , the new CD is required to review all current privileges,

practice agreements, and protocols, to ensure they are current, and they concur with

the provisions afforded within them. This review will take place within 60 days of the

CDs appointment. The CD will sign a memorandum to be placed in the credential file

of each health care provider attesting to the review. The 60-day time frame does not

give any providers additional time for their renewals of privileges, practice

agreements, or protocols. They are still required to be renewed prior to their

expiration date. If the Acting CD is selected for the CD position, the 60-day review

requirement will not apply, as it has already been completed.

 If any privileges, practice agreements, or protocols lack concurrence, updated and

signed privileges, practice agreements, or protocols must be obtained.

 Vacancies of institution CDOs.

 The Regional Chief Dentist will notify the Warden and HSA of the institution by

memorandum who the Acting CDO will be and include an effective date and an end

date not to exceed the appointment of a new CDO or current expiration date of the

Acting CDO’s privileges.

 The Regional Chief Dentist will be the Acting CDO when a vacancy occurs in the

CDO role at an institution within the region, unless otherwise delegated by

memorandum to another dentist. The acting delegation memorandum needs to be

placed in the providers credential file who is assuming the acting role.

 The dentist assuming the Acting CDO role is required to review all current privileges,

practice agreements, and protocols they are the privilege granting authority for, to

ensure they are current, and they concur with the provisions afforded within them.

This review will take place within 60 days of the CDO’s appointment. The CDO will

sign a memorandum to be placed in the credential file of each health care provider

attesting to the review. The 60-day time frame does not extend providers deadlines for

6027.03 5/7/2026 PROPERTY OF US GOVERNMENT 13

renewals of privileges, practice agreements, or protocols. They are still required to be

renewed prior to their expiration date.

 Once a Chief Dentist position is hired, , the new CDO is required to review all current

privileges, practice agreements, and protocols, to ensure they are current, and they

concur with the provisions afforded within them. This review will take place within

60 days of the CDO’s appointment. The CDO will sign a memorandum to be placed

in the credential file of each health care provider attesting to the review. The 60-day

time frame does not give any providers additional time for their renewals of

privileges, practice agreements, or protocols. They are still required to be renewed

prior to their expiration date. If the Acting CDO is selected for the CDO position, the

60-day review requirement will not apply, as it has already been completed.

 If any privileges, practice agreements, or protocols lack concurrence, updated and

signed privileges, practice agreements, or protocols must be obtained.

 Vacancies of Regional and Central Office health care providers. Vacancies of

Regional and Central Office health care providers will be referred to the Medical Director

or National Chief Dentist. The Medical Director will appoint acting Central Office

privilege granting authority to providers during vacancies (e.g., Acting Regional Medical

Director/Regional Chief Dentist). Those serving in the acting role will review all assigned

privileging packets within 60 days of appointment to ensure these are current and in

accordance with indented provisions.

 The Medical Director will appoint the Acting Regional Medical Director (RMD)/

Regional Chief Dentist (RCD) role in a memorandum that is placed in the Acting

RMD/RCD credential file.

 The Acting RMD/RCD will sign a concurrence memorandum to be placed in the

credential file of each health care provider reviewed during the period of vacancy.

 If alterations to the privileges are necessary, a new privilege application will be

completed within 60 days of appointment.

 The 60-day time frame does not give any providers additional time for their renewals

of privileges. They are still required to be renewed prior to their expiration date.

e. Emergency Clinical Support. In the event of a mass casualty incident, state of emergency,

or other disaster, the Bureau privileging authority (i.e., Medical Director) may authorize Bureau

clinicians who hold an active, unrestricted license and/or certification to be deployed to

institutions without the requirement for an active, signed privilege or practice agreement. This

provision is intended to facilitate the rapid deployment of qualified health care personnel in

critical situations only. Should the time of emergency deployment occur beyond 180 days, a peer

review will be conducted.