Site To Site Vpn Request Form PDF Details

In a world where the exchange of information between entities is paramount, especially within sectors where confidentiality and security are non-negotiable, such as the medical field, establishing secure communication channels is a critical task. The Medical IT Site-to-Site VPN Request Form serves a vital function in this context, facilitating a secure bridge between different networks. Specifically designed for the University of Miami, Miller School of Medicine, this form is the first step toward implementing a site-to-site IPSEC VPN, ensuring a protected flow of information. It encapsulates various essential details, including the requester's information, the vendor's credentials, and detailed technical parameters like VPN hardware, software/firmware versions, and the parameters required for setting up the VPN. The form's confidentiality clause reassures all parties involved that the information provided will be handled with utmost security. Completion of this form, followed by its submission via fax or email, initiates a process that is vital for the secure exchange of medical data, reflecting the institution's commitment to maintaining the integrity of its information systems. It's a mandatory procedure with a minimum processing timeline, emphasizing the importance of timely submissions. This form represents not just a request for technical connectivity but a crucial step towards ensuring that sensitive medical information is safeguarded through secure channels, highlighting the intersection of healthcare and information technology.

QuestionAnswer
Form NameSite To Site Vpn Request Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesipsec vpn request form, site to site vpn request form template, vpn template, vpn request form template

Form Preview Example

Medical IT Site-to-Site VPN Request Form

This form is to request a site-to-site IPSEC VPN with the University of Miami, Miller School of Medicine. All information held on the following worksheet will remain confidential.

When you have completed this form, please fax to (305) 243-6417 or e-mail to help@med.miami.edu (attn: Network Security).

Date of Request:

Needed By:

University of Miami Miller School of Medicine Sponsor Information:

UM Sponsor Name:

 

 

 

 

UM Sponsor Department:

 

 

 

 

 

 

 

 

 

 

 

 

 

UM Sponsor Email:

 

 

 

 

UM Sponsor Phone:

 

 

 

 

 

 

 

Vendor Company Information:

 

 

 

 

 

 

 

 

 

 

 

Vendor Contact Name:

 

 

 

Vendor Company:

 

 

Vendor Email:

 

 

 

Vendor Phone:

 

 

 

 

 

 

 

 

 

 

 

 

 

Parameters

 

UM Medical VPN

 

Partner VPN

 

 

 

 

 

 

 

 

 

 

VPN Hardware

 

Check Point

 

 

 

 

 

 

 

 

 

 

 

 

 

Software/Firmware Version

 

R75.20

 

 

 

 

 

 

 

 

 

 

 

 

 

VPN Gateway(s) IP

129.171.150.9

 

 

 

 

 

 

Digital Certificates

 

NO

 

 

 

 

 

Pre-shared key

 

YES

 

 

 

 

 

 

 

 

 

 

 

 

 

Authentication Method

 

Phase 1 (pre-g2-3des-sha)

 

 

 

 

 

 

 

 

 

 

 

 

 

IKE Method

 

Phase 2 (g2-esp-3des-sha)

 

 

 

 

 

Diffie-Hellman Group

 

Group 2 (1024 bits)

 

 

 

 

 

IPSec Encapsulation Mode

 

Tunnel

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Network List/Encryption

 

 

 

 

 

 

 

 

Domain

 

 

 

 

 

 

 

 

(Note: this list contains the sub-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

networks and/or specific hosts that

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

need to be accessed. Make sure to

 

 

 

 

 

 

 

 

include subnet masks)

 

 

 

 

 

 

 

 

We need your IT Department to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

supply an IP address for the

 

 

 

 

 

 

 

 

equipment.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Access requested (which

 

 

 

 

 

 

 

 

TCP/UDP ports/protocols and

 

 

 

 

 

 

 

 

applications will specifically

 

 

 

 

 

 

 

 

need to be opened)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Comments and Business Justification:

UM Sponsor Signature:

Date:

Requests take 48 hours minimum

E-mail to: help@med.miami.edu or fax to: (305) 243-6417

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