Access Request Form
For those without access to the eRegister system on KaleidaScope


The Access Request Security Policy portion of this form must be read, understood and agreed to by the requestor. A request for access will not be granted if the request is not job-related or if the request conflicts with Kaleida Health's Access Request Security Policy.
This form is intended for non-Kaleida staff who wish to view clinical information.

 
I would like access to: InfoClique    Powerchart    PACS    Helipad    Remote Access
Talent Management   
I would like training for: PACS   
How did you find out about InfoClique?:
Requestor Information
Access Type: Physician    Physician Support    Nursing Home    Insurance Company    Ambulance Company    Billing Company    Nursing Home Screener    Other   

Last Name

First Name

Middle Initial

Day Time Phone Number

Extension

Fax Number

Last 3 digits of SSN
//
Date of Birth

Job Title

Requestor E-Mail

Kaleida Associate Number - entering this number will help to expedite your request. If you don't know your Associate Number click HERE to perform a search for your number that you previously requested, or to request an Associate Number if you haven't already done so.

Question to assure identity in case of forgotten password
Answer to security question

The requested access should be the same as this person
Comments: