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.

AIR Requests have to go through the following steps in order to be approved to access Kaleida Health Systems.

Step 1: Organization Approval - your company manager has to approve the request.
Estimated Timeframe 1 - 14 days depending on time taken to approve request.

Step 2: Kaleida Manager Approval - an individual or point of contact who you work with at Kaleida Health has to approve your access request.
Estimated Timeframe 1 - 14 days depending on time taken to approve request.

Step 3: The request will be sent to our Human Resources system for processing and account creation.
Estimated Timeframe 1 - 2 days.

We are diligently working to process AIR Requests as quick as we can but at any point in the approval process we may have to verify demographic information which could result in longer processing times in order to fully approve access.

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

Demographic Information

First Name

Please provide a valid name.

Middle Initial

Please provide a valid middle initial.

If no middle initial, please check this box

Last Name

Please provide a valid name.

Suffix (optional)

Last four digits of SSN

Please provide a valid SSN.

If you do not have a SSN, please call the Service Desk at (716) 859-7777 as this information is used for validation purposes.

Date of Birth

Please select a valid date.

Organizational Email Address

(personal email addresses such as Yahoo, Road Runner, Gmail, Verizon are generic forms of email that do not support encryption)

Please provide a valid email.

Primary Phone Number

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

Organization Information

Organization/Institution

Please select a valid organization.

What is the legal name of your organization?

Remaining Characters: 25

Click on an organization below if this matches your organization name:

Physical Street Address

Please input a valid value.

Suite, Bldg, Floor #

Please input a valid value.

City

Please input a valid value.

State

Please input a valid value.

Zip

Please input a valid value.

What is your job title?

Please input a valid job title.

Choose a Site Administrator

Please choose the appropriate person from your company who will be responsible for approving and validating your access to Kaleida Health.

Please select a valid organization and approver.

Is your organization considered a covered entity?

Yes

Please select Yes / No.

Select a covered entity category

Please input a valid value.

Does the organization have a business agreement/service agreement/independent contractor agreement with Kaleida Health? If so, please send to this email address ITSecurity@kaleidahealth.org

Yes

Please select Yes / No.

Site NPI #:

Please provide a valid number.

Provide your organization's designated site administrative, this is the approver from your organization that can verify employment for all incoming requests. (usually HR dept.)

Organization Approver First Name

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

Organization Approver Last Name

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

Organization Approver Phone Number

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

Organization Approver Phone Number Extension

Please provide a valid phone number extension.

Organization Approver Email

Please provide a valid email.

How many employees of the organization are seeking access to the Kaleida Health Systems?

Please provide a valid value.

What is your formalized process for keeping Kaleida Health updated on your organizations involuntary/ voluntary terminations?

(We expect to be notified within 24 hours after an employee is terminated. If we are not notified within the required time frame, we reserve the right to remove your Organizations access to Kaleida Health Systems)

Please provide a valid response at least 40 characters long.

Who are the employees' of your organization who require access to Kaleida Health Systems? (please provide first and last name, comma-separated between names)

Please provide a valid response.

Provide the contact information for your Chief Information Officer (CISO) or other IT Department Leader.

CISO or IT Email address

Please provide a valid email.

CISO or IT Phone Number

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

Please call the Service Desk at (716) 859-7777 if your Organization Approver is not listed.

What does Approval Pending mean?

If you see an "approval pending" status, this means that this is a new company or approver that is currently being validated by Kaleida Health. Due to the time that it takes to validate necessary information, requests containing items with this status may take longer to approve.

Kaleida Health Details

Will you be working in a Kaleida Health Facility?

Yes

Please select a valid value.

Location

Please select a valid location.

What best describes the department you will be interacting with at Kaleida Health?

Please select a valid department.

What best describes the role you will be fulfilling as you work in partnership with the Kaleida Health network?

Please select a valid job.

Access Required Date

Please select a valid date.

What is your End Date?

Please select a valid date.

Additional Notes

Agreement

Information Technology Usage Agreement

1. Information Security

Access to Kaleida Health's information systems are subject to the Kaleida Health Information Security Policy (Policy #IT.01) It is the policy of Kaleida Health to protect its information assets and to allow the use, access and disclosure of such information only in accordance with its interests and applicable laws and regulations. It is Kaleida Health's legal and ethical obligation to protect the confidentiality of patient information. Users may only access the patients with whom they have direct job related responsibility to access. Access to patient data is subject to audit.

Access to any of Kaleida Health's systems is granted on a need-to-know basis. To accomplish this a user may be issued specific and confidential computer system ID's and/or passwords. These access identification codes may not be shared, disclosed or utilized by any other individual, inside or outside of Kaleida Health, including staff or people claiming to be staff of the Information Technology.

All printed information, as well as data storage media, including, but not limited to, , optical and magnetic storage media, is considered the property of Kaleida Health and is considered confidential matter. As such, this information shall not be shared, distributed, or stored in a careless manner.

The use of a computer or computer services without the permission of, or in excess of the permission of the owner or lessor, is prohibited by the Penal Law of the State of New York. The use of the Kaleida Health's network and/or computer systems for non-business purposes, or for personal gain, is prohibited. Users are required to preserve the security and confidentiality of any information assessable through the computer or network. Users are required to use all necessary and appropriate safeguards to prevent unauthorized use or disclosure of information they have access to. Users are permitted only to utilize or access information necessary for performance of their job. Use of technology can and will be monitored, thus limiting the potential for abuse. Unauthorized access or sharing of user IDs and passwords will lead to disciplinary action up to and including revocation of access and termination.

Users and department heads are responsible for notifying Human Resources and Cyber Security in the event of any change in user's responsibilities or the termination of user's services whether is it voluntary or Involuntary. It is the responsibility of the manager/supervisor to log in to KaleidaScope and under the Applications tab, choose Termination Process to begin.

Intellectual Property Infringement

Copyright, trademark and patent infringement is strictly prohibited. The federal Copyright Act extends to much of what is transmitted over computer networks, such as text, pictures, music and software. Since copyright infringement is a strict liability crime, intent to infringe is not required.

Kaleida Health has purchased the right to use software on personal computers that is protected by federal copyright laws. At no time may this software be copied for use on a personal computer other than the one for which it was originally intended.

Only software purchased or authorized by Kaleida Health may be used on its computers. Software brought in from outside or downloaded from the Internet, may not be used without approval from Information Technology., due to licensing issues, the exposure to computer malware and the potential impact on the Kaleida Health network. Any and all telephone conversations or transmissions, electronic mail or transmissions, or internet access or usage by a user by any electronic device or system, including but not limited to the use of a computer, telephone, wire, radio or electromagnetic, photoelectronic or photo-optical systems may be subject to monitoring at any and all times and by any lawful means.

Electronic Signature
Electronic Signatures are allowed for individuals with appropriate security levels in specific systems and/or application modules. For legal and medical reasons, the user of these systems must adhere to the security criteria setup to support and maintain the authentication of the electronic signature. The user must agree in writing to the fact that the "Electronic Signature" may be used instead of the traditional hand signature and must not be shared with anyone else.

2. Electronic Mail

The usage of Electronic Mail system is subject to the terms and conditions in the Kaleida Health Information Security Policy (Policy #IT.1) The Electronic mail system is the property of Kaleida Health and as such may be subject to disclosure for both business and legal purposes. Access to Kaleida Health's e-mail system is granted solely for the clinical and business purposes. All messages composed, sent or received on this system are and remain the property of the organization. Kaleida Health prohibits it to be used in any manner that would be disruptive to the operation or offensive to others. Any employee who receives sexually explicit or personally offensive materials electronically should report this to his or her supervisor and the Information Technology Department immediately. The use of electronic mail for transmission of information disparaging to others, for promotion of political causes or for personal gain is prohibited. Kaleida Health has the ability and right to monitor electronic mail at any time and without prior notification.

3. Internet Usage

Internet usage is subject to the terms and conditions in the Kaleida Health Information Security Policy (Policy #IT.1)The Internet is an international network of networks that connects businesses, government agencies, universities and individuals. It is considered a public network that poses additional risks to confidential information if proper precautions are not taken. For example, patient information transmitted via e-mail may be intercepted and disclosed without the knowledge of either the sender or receiver. It is required that all confidential information sent over the Internet be encrypted.

Internet communications that are not authorized to represent the organization's opinions should convey this fact within the body of the communication. Such language should convey the fact the user's opinions are not to be attributed to the organization.

While recognizing that the Internet contains hundreds of thousands of sites with potentially useful information, it's also obvious that it contains thousands of sites containing material, which is offensive, obscene or illegal. Visiting, viewing or downloading material from any Web site containing pornographic, sexist, racist, illegal material or material which is offensive in any way is strictly prohibited. Kaleida Health has the ability and right to monitor Internet traffic at any time and without prior notification.

Breaches of information security, intellectual property, Internet usage, electronic mail and electronic signatures including the sharing of access codes, identifications, or passwords, or wrongful access to the Kaleida Health network or systems connected to that network, are viewed as serious violations. Users violating this policy will be subject to disciplinary action, which may include but is not limited to termination of access to the system and termination of employment. Violators are also subject to civil or criminal liability.

I have read, understand, and agree with the terms and conditions as stated in this document.

Please review the entire IT Agreement and accept the terms and conditions.
You are required to scroll to the bottom and accept the terms.

Demographic Information

Demographic Information

Organization Information

Please choose the appropriate person from your company who will be responsible for approving and validating your access to Kaleida Health.

If you see an "approval pending" status, this means that this is a new company or approver that is currently being validated by Kaleida Health. Due to the time that it takes to validate necessary information, requests containing items with this status may take longer to approve.

Kaleida Health Details

Agreement

Submitting Request