INSTRUCTIONS: Chrishaun Jackson Chrishaun Jackson FAX the completed form to: For help completing this form contact, at or 860-418-6912 860-418-6896 HANDWRITTEN, incomplete, out of date, or Emailed forms will not be accepted. For questions regarding the VPN token, contact the DMHAS Information Technology Help Desk at: or 860-262-5058 User Information: Enter all user information, including your complete Facility Name, Address, Email and Phone Number. Name: First MI Last: Facility Name: Address: Street 1: City: Street 2: Zip: Email Address: Phone # : Ext: VPN A token is a device that will allow you to connect to the DMHAS secure network. If you need one, it will be mailed to you at the address above. Review the options listed and select the one that applies to you. If you are a DDaP user or VATS user, you can use your existing token or if you are a State Operator, you do not need a token; select or Already Have Token’. ‘N/A N/A or Already Have Change a Name on an existing token Serial # : First time Request for a Token Current User Name: Token was lost. Requesting a new one *New name will be the one listed above Access Request: If this is a first time request for access to CI, select If you had prior access and need to ‘NEW’. reactivate, select If you already have access, but need additional access (i.e., additional provider ‘Reactivate’. access), select Additional Access. NEW Reactivate Additional Access Additional Facilities: If you need CI access to more than one facility, enter the name(s) of the facilities below.
INSTRUCTIONS: For help completing this form contact, Chrishaun Jackson at or 860-418-6912 FAX the completed form to: Chrishaun Jackson 860-418-6896 HANDWRITTEN, incomplete, out of date, or Emailed forms will not be accepted. For questions regarding the VPN token, contact the DMHAS Information Technology Help Desk at: or 860-262-5058 User Information: Enter all user information, including your complete Facility Name, Address, Email and Phone Number. Name: First MI Last: Facility Name: Address: Street 1: City: Street 2: Zip: Email Address: Phone # : Ext: VPN A token is a device that will allow you to connect to the DMHAS secure network. If you need one, it will be mailed to you at the address above. Review the options listed and select the one that applies to you. If you are a DDaP user or VATS user, you can use your existing token or if you are a State Operator, you do not need a token; select ‘N/A or Already Have Token’. N/A or Already Have First time Request for a Token Token was lost. Requesting a new one Change a Name on an existing token Serial # : Current User Name: *New name will be the one listed above Access Request: If this is a first time request for access to CI, select ‘NEW’. If you had prior access and need to reactivate, select ‘Reactivate’. If you already have access, but need additional access (i.e., additional provider access), select Additional Access. NEW Reactivate Additional Access Additional Facilities: If you need CI access to more than one facility, enter the name(s) of the facilities below.
CI-VPN-Access-Form.docx