Associate Identity Request Form (A.I.R.)

Demographic Information

The Associate Identity Request Form (A.I.R. Form) is used to validate information about a user from a Kaleida Health Partner. When the A.I.R. form is received, CyberSecurity will submit the request to the Partners Organization Approver for approval and to the Kaleida Health Manager for approval. Upon approval, the user will receive a Kaleida Health "Associate" number. The “Associate” number will entitle the user to certain resources within Kaleida Health.

If you need assistance, please contact the Kaleida Health Service Desk at 716-859-7777.

Organization Information

Organization

Please select a valid organization.

Organization Name

Remaining Characters: 25

Please check the organization list above to ensure that it does not already exist. If not in this list, the organization is currently not affiliated with Kaleida Health and is under review for approval.

What is your job title?

Please input a valid job title.

Select an Organization Approver
Organization Approver is a person who can validate you work for the Organization you are applying for access on behalf of.

Please select a valid organization and approver.

Approver First Name

Approver Already Exists in the list above, please choose this approver or provide a valid name.

Approver Last Name

Approver Already Exists in the list above, please choose this approver or provide a valid name.

Approver Phone

Please provide a valid phone number ###-###-####.

Approver Email

Please provide a valid email.

Additional Details

Will you be working in a Kaleida Health Facility?

Yes

Please select a value.

What Kaleida Department are you working with?

Please select a valid department.

Location

Please select a valid location.

What do you need access to?

Eclipsys

EMR

InfoClique

Remote Access

Other (specify in notes)

Please select a valid access type.

Access Required Date

Please select a valid date.

What is your End Date?

Please select a valid date.

Additional Notes

Demographic Information

Demographic Information

Organization Information

Additional Details

Submitting Request