When an Association is to be established by a DICOM Upper Layer Entity, a TRANSPORT CONNECT request primitive shall be issued to the TCP Transport Service (Active Open). Once the TCP Transport Connection Confirmation is received (Open Completed), an A-ASSOCIATE-RQ PDU shall be sent/written on the now established transport connection.

When a DICOM Upper Layer Entity becomes activated (Association Idle State), it shall wait for TCP Transport Connections in a passive mode by initiating a “listen.” When an incoming TCP Transport Connection Indication is received from the network, it is accepted and a timer ARTIM (Association Request/Reject/Release Timer) shall be set. Any further exchange of PDUs (read/write) shall be performed as specified by the Upper Layer State Machine (including ARTIM Timer expiration before an A-ASSOCIATE-RQ PDU is received, see Section 9.2).