Medical Designations and Referral Services for Federal Prisoners

By Elizabeth Franklin-Best, Esq., and Christopher Zoukis, JD, MBA

Program Statement 6270.02 at a glance

Field	Value
Program Statement	6270.02, Medical Designations and Referral Services for Federal Prisoners
Subject	How the Bureau of Prisons decides which facility can handle a person’s medical or psychiatric needs, who makes that decision, and how someone is physically moved to a Medical Referral Center or a Care Level 3 institution
Effective / current edition date	May 7, 2026 (PDF header: “Number 6270.02 / Date May 7, 2026”), approved by Director William K. Marshall III; office of primary responsibility DPI HSD
Change notice	None
Supersedes / rescinds	“Program Statement Rescinded: 6270.01 Medical Designations and Referral Services for Federal Prisoners (1/15/2005)” — a 21-year-old policy
Governing statute	The PS’s REFERENCES block cites only 18 U.S.C. §§ 3552, 4241–4247 and 4248 — the forensic-evaluation statutes, which govern § 3.d of the policy, not medical designation generally. The Bureau’s placement authority is 18 U.S.C. § 3621(b), which the PS does not cite
Governing regulation (28 C.F.R.)	None. The PS’s REFERENCES block cites no C.F.R. section. There is no regulation codifying the Care Level system
Related BP forms	BP-A0659, Medical Summary of Federal Prisoner/Alien in Transit; BP-A0770, Medical/Surgical and Psychiatric Referral Request. Other forms named: EMS-A206.060, Medical Resources Directory; USM-553, Prisoner in Transit Medical Summary
Official PDF	PS 6270.02, Medical Designations and Referral Services for Federal Prisoners (May 7, 2026)

Checked against the BOP policy set · 2026-09-06.

Program Statement 6270.02 governs medical designation: the process by which the Bureau’s Office of Medical Designations and Transportation decides that a person’s health needs exceed what their current prison can provide, and moves them somewhere that can. It is the policy behind a transfer to a Medical Referral Center, behind the Care Level 3 and Care Level 4 designations, and behind the air ambulance that occasionally carries someone across the country.

This page explains the designation and transfer machinery. For how care is delivered once someone is at a facility — sick call, chronic care clinics, treatment refusal — see Patient Care (PS 6031.06). For the $2.00 sick-call fee, see the Inmate Copayment Program (PS 6032.01). And for the practical side — what a family can actually do when a transfer is needed and not happening — see care levels and medical designation, which is the companion to this page.

The rule itself: care levels, who designates whom, and the transfer priorities

One thing has to be said before the tables, because it is the single most misunderstood fact about this policy.

PS 6270.02 does not contain a Care Level 1–4 definition table. It uses Medical Care Levels 1 through 4 and Mental Health Care Levels 1 through 4 on almost every page, but it never defines them. It points elsewhere twice: the criteria for classifying an individual live in a non-public Bureau document, “Care Level Classification for Medical Conditions or Disabilities Clinical Guidance,” which PS 6270.02 § 1 lists as the first basis on which OMDT designators make decisions and which sits on the Bureau’s internal intranet, not on bop.gov. The definitions of the institution care levels are printed in a different Program Statement — Patient Care, PS 6031.06 § 6. Those institution definitions are reproduced below, pin-cited to where they actually appear.

The four medical care levels — verbatim from PS 6031.06 § 6

Care level	Definition as printed in PS 6031.06
Care Level 1	“Care Level 1 institutions house inmates who are generally healthy but may have limited medical problems easily managed by Health Services staff and supplemented by existing community resources.”
Care Level 2	“Care Level 2 institutions house inmates who have stable chronic conditions managed by Health Services staff and supplemented by existing community resources. Care Level 2 inmates generally self-manage their conditions and need infrequent visits to medical specialists or community facilities.”
Care Level 3	“Care Level 3 institutions house inmates who have more complex medical conditions and are more fragile. They require frequent clinical contacts with Health Services staff and more visits to community medical specialists. They may also periodically require hospitalization to stabilize their conditions.”
Care Level 4	“Care Level 4 institutions are the Bureau’s MRC. Inmates housed at MRCs may require extensive medical and nursing care. Some inmates may require 24-hour nursing care including assistance with activities of daily living such as feeding, toileting, and dressing. These inmates may have frequent visits to medical specialists or hospitalizations for specialized medical care that isn’t available in the MRC.”

Source: PS 6031.06 at pp. 12–13. MRC = Medical Referral Center.

The framing sentence is also from Patient Care, and it explains why two numbers exist for every person: “Medical classification is a system by which the Bureau assigns a medical and mental health care level both to inmates and Bureau facilities. For inmates, the care level is determined by their medical needs and based primarily on the chronicity, complexity, intensity, and frequency of interventions and services that are required, as well as an inmate’s functional capability. For facilities, the care level is based primarily on the clinical capabilities and resources of the institution and the surrounding community, as well as specific medical missions (e.g. dialysis, oncology, etc.). Classifying both the inmate and facility allows the Bureau to match inmate medical and mental health needs with a facility resourced to care for those needs” (PS 6031.06 § 2.o at p. 5). Mental health care levels are set out in a third document, the Psychology Services Manual.

Who designates whom — the OMDT/DSCC split

This is PS 6270.02’s own operative rule, and it is the answer to “who do I have to convince.” Verbatim from § 3.a:

• “Inmates with major medical/psychiatric problems, or those with chronic care requirements, are referred to OMDT by DSCC for initial review to determine a care level.”
• “OMDT will designate Medical Care Level 3 or 4 and Mental Health Care Level 4 (CARE4-MH) inmates.”
• “OMDT will return Medical Care Level 1 and 2, and Mental Health Care Level 1, 2, and 3 cases to DSCC for placement in an appropriate institution.”
• “Initial designations are assigned a Screening Care Level (SCRN) which is entered into the applicable Bureau inmate management system. During the initial comprehensive medical and psychological evaluation at the institution, the SCRN care level is assessed and changed to a non-provisional Care Level.”
• “Medical Screening Care Levels are assigned using available medical records and information provided in the Pre-Sentence Report.”
• “Mental Health Screening Care Levels 3 or 4 are assigned in consultation with the Mental Health Treatment Coordinator and/or the Bureau Chief Psychiatrist.”
• “SCRN care levels must be changed to a non-provisional care level in the applicable Bureau inmate management system in order for the inmate to be re-designated to another institution.”

Source: PS 6270.02 at p. 5. OMDT = Office of Medical Designations and Transportation; DSCC = Designation and Sentence Computation Center, Grand Prairie, Texas.

Two of those bullets are the ones that decide cases. A Care Level 1 or 2 medical designation is a DSCC matter — the ordinary designation office. Care Level 3 and 4, and Mental Health Care Level 4, are OMDT matters, decided by clinicians in Central Office. And a provisional (SCRN) care level blocks any re-designation until it is converted to a real one at the first comprehensive evaluation. That single sentence is the reason a great many transfer requests go nowhere.

The policy also lists what must be considered before an initial medical or mental health designation, verbatim: “the inmate’s medical and psychiatric needs; the inmate’s security needs; proximity to the inmate’s home; transportation requirements; recommendations made by the sentencing judge” (PS 6270.02 at p. 5).

The four OMDT designation priorities

Priority	Definition as printed in PS 6270.02
Routine	“A Routine transfer is initiated for medical, surgical, or psychiatric treatment that is not urgent or emergent and time en route is not a major factor. Routine transfers may travel by any means.”
Routine Urgent	“A Routine Urgent transfer is initiated for medical, surgical, or psychiatric treatment that is not an emergency, but must be transported directly to an MRC due to the acuity of their medical, surgical, or psychiatric condition, or because MRC-based services need to be initiated within a specific time frame.” Direct Transportation “is defined as air ambulance, air charter, or ground ambulance”; holdover status “at a county jail or Bureau general population institution is not permissible for Direct or Routine Urgent transfers”
Emergency	“An emergency transfer is a medical, surgical, or psychiatric condition determined by medical/mental health staff to require immediate, direct transportation. … OMDT designators process these cases within 72 hours of receipt, which may be extended when additional documentation from the institution is required.” Emergency referrals require air ambulance, air charter, or emergency ground transportation. “Any case that can be moved via regular Bureau transit (e.g. Bureau bus, Bureau/USMS airlift) cannot be declared an emergency transfer”
Care Level 3 Re-designation with Direct Transfer	“Some Medical Care Level 3 inmates will require direct transfer if their medical condition puts them at risk for adverse events during holdover status at a county jail or Bureau general population institution. The decision to require direct travel for a Care Level 3 designation is made by the Chief, Health Programs (CHP).”

Source: PS 6270.02 § 4 at pp. 6–7.

The two request forms — 770 and 413

Every medical re-designation runs on one of two electronic requests, and they move in opposite directions.

Form	What it does	When it is used
Re-Designation Referral Request (770)	“A 770 provides all the designation, transportation, and security information required to complete a designation.”	“Re-designation to a higher level of medical or mental health care (i.e., Medical Care Level 3 facility, MRC, or Mental Health Care Level 4 facility)”; “To request a transfer of a Medical Care Level 3 or 4 inmate to another Medical Care Level 3 or 4 facility, or to request transfer from a Medical Care Level 4 to a Medical Care Level 3 facility”; “Emergency referral requests”
Treatment Complete Referral Request (413)	“A 413 request serves as the notification that medical or mental health treatment has been completed and provides all of the designation, transportation, and security information required to complete a re-designation to a Medical Care Level 1 or 2 facility or a Mental Health Care Level 1, 2, or 3 facility.”	Initiated “for inmates who have completed the necessary clinical procedures or treatments as determined by NURAB and are ready to return to an appropriate Medical Care Level 1 – 2 institution, or Mental Health Care Level 1 – 3 institution.” A 413 “also require[s] Unit Team or Case Management recommendations for placement”

Source: PS 6270.02 §§ 3.b, 3.c, 5 at pp. 5–6, 10. NURAB = National Utilization Review Advisory Board.

Both are completed in the Electronic Health Record — “unless the inmate is in community custody, then a medical BP-A0770, Medical/Surgical and Psychiatric Referral Request (770) will be used” (PS 6270.02 § 5 at p. 7). Two implementing instructions in § 5 matter to families and counsel more than the rest of the section combined:

“The determination as to whether an inmate is approved for re-designation depends on the 770 or 413 being completed thoroughly. If a 770 or 413 request does not include the necessary information for OMDT to make a determination, OMDT will defer the request and the institution will be responsible for submitting a new request with the required documentation.”

“Institutions are responsible for scheduling and continuing all medically necessary treatment and ongoing medical care for inmates who have been approved for re-designation by OMDT, but who have not physically transferred to the receiving facility. Failure to provide necessary treatment while awaiting physical transfer after re-designation could result in a delay in care.”

Source: PS 6270.02 at p. 8.

The second of those is new in the 2026 edition. It closes a gap that used to swallow people whole: approved for transfer, waiting for a bed, and treated by nobody in the meantime.

Where an approved person is sent

If a medical re-designation is approved, “the Medical Designator will select the most appropriate Care Level 3 facility or MRC based on the following,” verbatim: “Inmate’s medical needs; Security/custody level; Central Inmate Monitoring System (CIMS) considerations (e.g., separatees); Custodial concerns; Care Level 3/MRC bed space availability; Proximity to the inmate’s primary residence. A facility as close to or, to the extent practicable, within 500 driving miles of the inmate’s primary residence will be chosen” (PS 6270.02 at p. 9). That last factor tracks the statute: 18 U.S.C. § 3621(b) directs the Bureau to “place the prisoner in a facility as close as practicable to the prisoner’s primary residence, and to the extent practicable, in a facility within 500 driving miles of that residence,” subject to bed availability, security designation, programmatic needs, medical and mental health needs, faith-based requests, court recommendations, and Bureau security concerns.

For emergencies the list is shorter and different: “Available medical resources; Proximity to the sending institution; Security/custody needs; Custodial concerns; Bed space availability” (PS 6270.02 at p. 10). Note that proximity to home drops out of the emergency criteria entirely and is replaced by proximity to the sending institution.

Conditions that bar transport on the Bureau/USMS airlift

Section 9 is the most concrete list in the document, and it explains why a person who has been approved for a medical transfer still does not move. Verbatim: “Generally, the following conditions will not be considered for transport on the Bureau/USMS airlift”:

• “type I diabetes (must be direct transfer)”
• “unstable cardiac conditions”
• “severe chronic obstructive pulmonary disease (COPD)”
• “pregnancy in the third trimester and those with a history of spontaneous abortion” — “exception: authorization by an obstetrician given within 72 hours of departure allowing air travel by direct transport without holdover stops”
• “acute psychosis”
• “symptomatic sickle cell disease or previous history of attacks with air transportation” — “Required sickle cell documentation and labs must be completed by medical staff and documented in the Exit Summary prior to transfer”
• “inmates who require respiratory equipment, including oxygen”
• “inmates who have a history of myocardial infarction (MI) with restricted ambulation and/or suffer from angina with slight or moderate exertion”
• “any inmate who is unable to walk”
• “any dental appliance or device which prevents the mouth from opening”
• “hemoglobin (Hgb) that is not at least Hgb 8 mg/dL or above” — “If no current laboratory information is available, travel will be approved for ground transportation only”

Source: PS 6270.02 § 9 at pp. 14–15.

The same section gives the flight nurse an independent veto: “A USMS-employed Flight Nurse accompanies all flights. The Flight Nurse has the authority to exclude any inmate, including a medically re-designated, routine level inmate, from the flight based on: information, or lack of information, presented in the transfer packet; evaluation of the inmate’s current condition prior to boarding; medical information provided on the Exit Summary; inmate not medicated prior to transfer; inmates without a seven-day supply of medication.”

The seven modes of transport

Mode	What PS 6270.02 says	Pin-cite
Air Ambulance	“Air ambulance is utilized for inmates who are bed bound, cannot maintain a seated position for transfer, or will require in-flight medical care.” The Clinical Director “must certify the inmate is stable before a transfer.” Normally staffed by a Flight Nurse or Physician	§ 8.a at p. 13
Air Charter	“Generally referred to as Specialized Operation Air Program (SOAP) flights, are private flights typically utilized for emergent/Routine Urgent travel over 400 miles”	§ 8.b at p. 13
Ground Ambulance	“A ground ambulance may be used to transfer inmates who are near an MRC, e.g., USP Leavenworth to USMCFP Springfield”	§ 8.c at p. 13
Institution Vehicle	“[M]ay be used for emergency and direct transfers if the Clinical Director certifies this is a safe and appropriate mode of transportation”	§ 8.d at p. 14
Commercial Air	“The Warden may authorize commercial air transportation for Routine and Routine Urgent transfers.” But “[i]nmates for whom an MRC was designated for mental health treatment will not be transported by commercial air”	§ 8.e at p. 14
Bureau/USMS Airlift (JPATS)	“This may be used for Routine transfers only”	§ 8.f at p. 14
Bureau Bus	“This may be used only for Routine transfers when it is the most efficient means of transfer”	§ 8.g at p. 14

Source: PS 6270.02 § 8 at pp. 13–14.

Across every mode the policy repeats one rule: “Under no circumstances will inmates be transported who are not in stable condition. The current treating provider and/or Bureau institution Clinical Director must certify the inmate is stable for medical transport prior to travel authorization being granted” (PS 6270.02 § 10.b at p. 15).

What medical designation policy means for you

If you are the person inside: why you cannot file this request

The request does not start with you, and it is not a cop-out you can file. A medical re-designation begins when “[t]he institution provider or staff member will initiate the 770,” which “[t]he Clinical Director and HSA must review … authorize the transmission of the request, and notify the institution Warden” (PS 6270.02 at p. 8). In other words, a clinician at your institution has to write it and your Clinical Director has to send it. What you can do is give them the reason to.

Three practical points. First, the SCRN problem: if your care level is still provisional, the policy says re-designation cannot proceed until it is converted at your first comprehensive medical evaluation. If you arrived recently and are being told a transfer request is not possible, this may be why, and asking whether your care level is still SCRN is a specific question with a specific answer. Second, the care level itself is reviewed at every comprehensive medical evaluation and chronic care clinic visit under PS 6031.06 § 12.a — that visit, not a separate process, is where a care-level change is made. Third, if you have been approved and are waiting, the 2026 edition now says in terms that your institution remains responsible for “scheduling and continuing all medically necessary treatment and ongoing medical care” while you wait. Being approved for transfer is not a reason to stop treating you.

Where you need a written record, the vehicle is a BP-A0148 Inmate Request to Staff to the Health Services Administrator or Clinical Director, asking whether a 770 has been submitted, on what date, and what OMDT’s response was. That is answerable, and the answer is the foundation of anything that follows.

If you are a family member: who actually decides

The decision-maker is not the warden. It is a designator at the Office of Medical Designations and Transportation, working with the Chief, Health Programs, the Regional Medical Director, and the Bureau Chief Psychiatrist. PS 6270.02 § 1 puts it bluntly: “the OMDT clinical and DSCC custody/security authority supersedes local clinical and executive decision making.” Letters to a warden asking for a medical transfer are aimed at the wrong office — though a warden’s support can still matter, because the request originates locally.

The most useful thing you can supply is documentation. OMDT decides on the paper in front of it, and the policy says explicitly that an incomplete request will be deferred and sent back to the institution to redo. Outside specialist reports, imaging, pathology results, a treating oncologist’s staging letter, a nephrologist’s dialysis order — anything that establishes complexity, intensity and frequency of care — belongs in your loved one’s Health Services file, and getting it there is something you can do without a lawyer. Ask your loved one to execute a BP-A0621, Authorization for Release of Medical Records so information can move in both directions.

Finally, adjust expectations about geography. Proximity to home is one of six factors OMDT weighs, and it is the last of the six as the policy lists them. In an emergency it is not a factor at all — the policy substitutes proximity to the sending institution. A move to appropriate medical care frequently means a move further from home, and there is no policy that entitles anyone to a particular facility.

If you are counsel: medical designation

Frame the question as a care-level question, because that is the vocabulary of the deciding office, and build the record OMDT actually reads.

The four decisional documents are identifiable and requestable. The 770 or 413 itself. The care level assignment history, including whether it is still SCRN. The Medical Resources Directory (EMS-A206.060) for the current institution — under § 2.d each institution’s Health Services Administrator maintains it “listing the availability of specialized medical and mental health services on-site, such as dialysis, blood transfusions, wound care, intravenous antibiotics, Residential Drug Abuse Treatment Program (RDAP), and physical therapy,” updated “at least quarterly.” That directory is the document that establishes what a facility can and cannot do, which is the crux of most designation disputes. And the Exit Summary, which “must accompany all inmates in transit regardless of physical or mental condition or reason for transfer” (§ 7 at p. 12).

Know the two escalation paths inside OMDT, because they tell you who the real audience is. For a medical 770: “Care Level 3 requests are assigned to the Regional Medical Director (RMD) for their concurrence or disapproval. The 770 is then assigned to the OMDT Medical Designator for a final review and determination. If the OMDT Medical Designator and the RMD have differing recommendations, the 770 will be electronically sent to the CHP in the EHR for final determination.” For Care Level 4: “requests are reviewed by the assigned Medical Designator. The Medical Designator may approve the request; however, all recommendations for disapproval are referred to the CHP for final determination.” For a mental health 770, Care Level 4 requests go “to the Bureau Chief Psychiatrist for final determination” (PS 6270.02 at pp. 8–9).

Two structural cautions. First, PS 6270.02 rests on no regulation — its REFERENCES block cites no C.F.R. section, and the statutes it cites (18 U.S.C. §§ 3552, 4241–4247, 4248) govern only the forensic designations in § 3.d. The general placement authority is 18 U.S.C. § 3621(b), which the policy tracks but does not cite. Second, designation is discretionary by statute and by policy, and the Care Level criteria for individuals are in a clinical guidance document the Bureau does not publish. Both facts belong in any candid advice to a client about what a designation challenge can and cannot achieve. Where inadequate care is the real claim, the constitutional standard is Estelle v. Gamble, 429 U.S. 97 (1976) — “deliberate indifference to serious medical needs of prisoners constitutes the ‘unnecessary and wanton infliction of pain’ … proscribed by the Eighth Amendment,” but “a complaint that a physician has been negligent in diagnosing or treating a medical condition does not state a valid claim” — with the mental state supplied by Farmer v. Brennan, 511 U.S. 825 (1994). Both retrieved and read this session: Estelle and Farmer.

What changed with Program Statement 6270.02

PS 6270.02 replaced a policy that had been in force since January 15, 2005 — twenty-one years. The reissue rewrote much of it, and the Summary of Changes on pages 1 and 2 lists sixteen items. The ones that change outcomes:

• “Changes length of hospitalization from five to 10 days to seven to 14 days in Section 2.a.” The current text reads: “Most institutions will be able to locally manage hospitalizations between seven and 14 days for acute medical care or surgical procedures followed by one to three post-operation appointments.” A longer local-management window means fewer hospitalizations trigger a transfer.
• “Clarifies Office of Medical Designations and Transportation (OMDT) vs Designation and Sentence Computation Center (DSCC) designation responsibility for initial designations in Section 3.a.” This is the OMDT/DSCC split reproduced above.
• “Adds requirement for SCRN care level to be changed to non-provisional care level at the first comprehensive health assessment after initial designation in Section 3.a.” And the corollary that a provisional level blocks re-designation.
• “Adds Section 3.c. Treatment Complete Referral Request (413),” “Adds Section 3.d. Forensic Designation,” and “Adds Section 3.e. Mental Health Care Level 4 Designations” — three processes that were not separately described in the 2005 edition.
• “Removes two to three week time requirement for Routine Urgent designations in Section 4.b.” The prior edition set an outer window for Routine Urgent moves; the current one does not.
• “Adds Section 4.d. Care Level 3 Re-designation with Direct Transfer.”
• “Adds explanation of OMDT deferral procedure for incomplete re-designation requests to Section 5” and “Adds explanation of duty to treat inmates until physical transfer to a Medical Referral Center (MRC) or Care Level 3 institution occurs in Section 5.”
• “Adds Section 6: OMDT Prioritization of MRC Re-designations” — a weekly review of everyone pending transfer, with emergency transfers taking priority over Routine and Routine Urgent.
• “Changes Hemoglobin requirement to 8 mg/dL in Section 9.b.”
• “Removes Section 10.d. Procedures for Long Term Detainees.”
• “Adds requirement to attach Special Investigative Services (SIS) reports to custodial requests in Section 2.f.”

Source: PS 6270.02 at pp. 1–2.

Two changes cut in opposite directions and should be read together. Lengthening the local hospitalization window from 5–10 days to 7–14 days and removing the Routine Urgent time requirement both reduce the number of situations in which a transfer is triggered or time-bound. Adding the deferral explanation and the duty-to-treat-while-waiting language both increase what an institution owes a person who is in the queue. Anyone comparing the 2005 and 2026 editions should not describe the reissue as uniformly favorable or unfavorable; it is neither.

One more thing changed outside this document. The Bureau’s designation and computation office at Grand Prairie, Texas — DSCC — and Central Office are separate from OMDT, and the 2026 edition is the first to state the authority relationship among them plainly: “OMDT will work directly with DSCC when there are rare and compelling custody reasons not to designate or transfer the inmate to the most appropriate medical destination. To this end, the OMDT clinical and DSCC custody/security authority supersedes local clinical and executive decision making” (PS 6270.02 § 1 at p. 2). Under the same section, “[t]hrough the Medical Director, OMDT and the National Utilization Review Advisory Board (NURAB) have full authority over all Care Level 4 (inpatient) medical bed management decisions including admission and discharge.”

Where people get stuck on a provisional care level

The care level is still provisional

Section 3.a says a Screening Care Level is assigned at initial designation from “available medical records and information provided in the Pre-Sentence Report,” and that “SCRN care levels must be changed to a non-provisional care level in the applicable Bureau inmate management system in order for the inmate to be re-designated to another institution.” A person whose serious condition was thinly documented in the presentence report can therefore arrive with a provisional level that does not reflect their needs, and stay stuck behind it. The fix runs through the first comprehensive medical evaluation described in PS 6031.06 § 11 — due within 14 days for someone with a chronic or new condition — where the care level is set for real. A written request to Health Services asking whether the SCRN level has been converted, and on what date, is the first concrete step.

The request was “deferred,” which is not the same as denied

OMDT deferral means the paperwork was incomplete: “the institution will be responsible for submitting a new request with the required documentation.” Families often hear “denied” and stop. A cop-out to the Health Services Administrator asking whether a 770 was submitted, whether OMDT deferred it, and what documentation OMDT identified as missing turns an apparent dead end into a to-do list. If the institution simply does not act, the Administrative Remedy Program applies: informal resolution, then a BP-9 within 20 calendar days of the event, a BP-10 within 20 days of the Warden’s signed response, and a BP-11 within 30 days of the Regional Director’s (28 C.F.R. § 542.15). Where health is genuinely at risk, 28 C.F.R. § 542.18 requires a Warden response “not later than the third calendar day after filing” for a request “of an emergency nature which threatens the inmate’s immediate health or welfare,” and permits treating a missed deadline as a denial so the appeal can move up.

Approved for transfer, and nothing happens

Two different things stall an approved transfer, and they have different answers. One is bed space: § 6 provides that OMDT, with the Chief Health Programs, the Mental Health Treatment Coordinator and the Bureau Chief Psychiatrist, “review all inmates pending transfer to MRCs each week for appropriate priority for transfer,” and that “[t]he priority and/or facility are subject to change depending on the inmate’s condition at the time of the review.” A change in condition is therefore a reason to ask for re-prioritization, not just to wait. The other is the airlift exclusion list in § 9 — a person on oxygen, unable to walk, with a hemoglobin under 8 mg/dL, or in acute psychosis is not going on a JPATS flight, and the transfer will need a direct-transport mode that costs more and takes longer to arrange. Meanwhile, the 2026 edition’s duty-to-treat sentence applies: the sending institution remains responsible for ongoing care until the person physically moves.

The medical transfer costs the family the visits

This is real, and it is worth saying plainly rather than pretending otherwise. Proximity to a person’s primary residence is the sixth of six factors an OMDT designator weighs for a non-emergency medical re-designation, and it drops out of the emergency criteria entirely. Under 18 U.S.C. § 3621(b) the Bureau is directed to place someone “as close as practicable” to home and, “to the extent practicable,” within 500 driving miles — but that direction is expressly “subject to bed availability, the prisoner’s security designation, the prisoner’s programmatic needs, the prisoner’s mental and medical health needs,” and other Bureau security concerns. Medical need routinely outweighs distance. Where the family’s ability to visit and support is itself part of the medical picture, that belongs in the record as a documented clinical consideration rather than as a request — and where distance is the real problem, the later 413 (treatment complete) request is the point at which placement near home comes back into play, because a 413 requires Unit Team recommendations for placement.

Related BOP policy on medical designation

Page	What it covers
Care levels and medical designation	The practical companion: what a family can do about a designation, and what a consultation looks like
Medical care in federal prison	The overview of medical care and medical disputes
Patient Care (PS 6031.06)	Where the Care Level 1–4 definitions are actually printed, plus sick call and chronic care
Inmate Copayment Program (PS 6032.01)	The $2.00 fee and the eight exempt services
Security designation and custody classification (PS 5100.08)	The custody-side designation process DSCC runs, which medical designation sits alongside
Treatment and Care of Inmates with Mental Illness (PS 5310.16)	Mental health care levels and CARE4-MH designations
Management of Aging Offenders (PS 5241.01)	Age accommodations, and why age alone does not change a designation
Escorted trips (PS 5538.08)	The correctional coverage side of a medical trip
Furloughs (PS 5280.09)	Medical furloughs, which PS 6270.02 § 2.i cross-references
Administrative Remedy Program (PS 1330.18)	BP-8 through BP-11, with the emergency response provision
Inmate Request to Staff (PS 5511.08)	The BP-A0148 cop-out
Compassionate Release / Reduction in Sentence (PS 5050.51)	Where a Care Level 4 medical picture often leads next

Frequently Asked Questions About Medical Designations and Care Levels

Reviewed for legal accuracy by Elizabeth Franklin-Best, Esq., Principal Attorney·September 2026