EXPLICIT CONSENT FORM REGARDING THE PROCESSING OF PERSONAL DATA

Pursuant to the Law No. 6698 on the Protection of Personal Data and the Regulation on the Processing and Protection of Privacy of Personal Health Data, DR. ARSLAN POLYCLINIC requests your explicit consent regarding the matters stated below, except for cases where your personal data specified in the Patient/Service Recipient Disclosure Text within the Scope of Personal Data Protection, which has been presented to your information in accordance with the relevant provisions, is processed and transferred to the extent necessary for the protection of public health, medical diagnosis, examination, treatment, and care services;

  1. Collection and Processing of Personal Data:

I have read and been informed through the Patient/Service Recipient Disclosure Text within the Scope of Personal Data Protection, which was presented to me, that my personal data may be obtained verbally, in writing, visually, or electronically depending on the nature of the service provided, in order to provide me with high-quality service.

Within this scope, my personal health data, primarily those required for the execution of all medical diagnosis, examination, treatment, and care services and obtained for this purpose, as well as the main general and special categories of personal data obtained, are listed below;

  • My identity information; my name, surname, Turkish Republic Identification Number, copy of my driver’s license, passport number or temporary Turkish Republic Identification Number, place and date of birth, marital status, gender, insurance or patient protocol number, and other identity information that may identify me.
  • My Contact Information: My address, telephone number, e-mail address, and other contact data; my voice call records kept by customer representatives or patient services in accordance with call center standards; and my personal data obtained when I contact the Hospital via e-mail, letter, or other means.
  • My Financial Information; my bank account number, IBAN number, credit card information, billing information, and other financial data.
  • Camera and photograph records kept for security purposes if I visit your hospital, my vehicle license plate data if I use parking and valet services, and related photograph and camera records.
  • Closed-circuit camera system images and records obtained during my visit to your hospitals,
  • My Health Information; my general and special categories of personal data, particularly my personal health data obtained during the execution of all medical diagnosis, examination, treatment, and care services and submitted by me to you; for example, my appointment and examination information, laboratory results, test results, check-up and prescription information, and the data specified in the consent form in the event of a medical intervention,
  • My survey, suggestion, satisfaction, thank-you, and complaint data; my browsing information obtained through e-mail, website contact forms, your website, and mobile applications if used; my IP address, Wi-Fi information, browser information, and medical documents, surveys, relevant records and form information that I submit to you through the same system with my own consent, or other data I share with you through other means, including my private health insurance data and similar data for the financing and planning of healthcare services.
  1. Purposes of Processing Personal Data:

I have been informed that my Personal Data and Special Categories of Personal Data listed above may be processed for the following purposes;

  • Fulfilling legal obligations set forth in the Basic Law on Healthcare Services No. 3359, the Decree Law No. 663 on the Organization and Duties of the Ministry of Health and its Affiliated Institutions, the Public Health Law No. 1593, the Patient Rights Regulation, the Private Hospitals Regulation, the Regulation on Personal Health Data, and other relevant regulations;
  • Protection of public health, preventive medicine, execution of medical diagnosis, treatment, and care services, planning and management of healthcare services and their financing, execution of all medical diagnosis, examination, treatment, and care services, and provision of medicines, consumables, and special materials,
  • Providing you with information regarding your appointment if you make one; verifying your identity; issuing invoices; and ensuring that your procedures are planned, managed, and monitored quickly and accurately,
  • Ensuring financial reconciliation with contracted institutions regarding the healthcare services provided to you; responding to requests from public institutions and organizations in accordance with legislation
  • Measuring patient satisfaction after you receive healthcare services and improving patient satisfaction; responding to all your questions and complaints; providing information regarding the services offered to you;
  • Improving quality processes and carrying out related activities;
  • Researching and analyzing my use of healthcare services in order to improve the services offered to me,
  • Enabling participation in campaigns and providing campaign information by the relevant departments through all communication channels,
  • Measuring the satisfaction of patients receiving healthcare services from your hospital and improving patient satisfaction,

I have been informed in detail that my data will be processed, recorded, stored, retained, classified, and, in matters concerning public security and in any legal disputes that may arise, transferred upon request and as required by legislation to public prosecutors’ offices, courts, all judicial authorities, the General Directorate of Population and Citizenship Affairs, the Turkish Medical Association, the Turkish Pharmacists’ Association, and relevant public officials; and, where necessary, within the scope of the purposes specified above, to authorized public institutions and organizations, institutions and organizations to which referrals are made, healthcare institutions and organizations with which you cooperate for medical diagnosis and treatment, laboratories, business partners, private insurance companies, law firms, financial advisors, and all consultants, including third parties from whom you receive consultancy services.

  1. Methods of Collecting Personal Data and Legal Grounds:

I know that the legal grounds for the collection of my Personal Data are based on the Law No. 6698 on the Protection of Personal Data, the Basic Law on Healthcare Services No. 3359, the Decree Law No. 663, the Private Hospitals Regulation, and the relevant legislation.

I have been informed that my personal data shared in the Disclosure Text may be processed within the scope of the purposes specified in the Disclosure Text on the legal grounds set forth in Articles 5 and 6 of Law No. 6698, namely: (i) being expressly provided for by law, (ii) being necessary for the processing of personal data belonging to the parties of a contract, provided that it is directly related to the establishment or performance of a contract, (iii) being mandatory for the protection of the life or physical integrity of the person or another person where the data subject is unable to express consent due to actual impossibility or whose consent is not legally valid, (iv) being mandatory for the data controller to fulfill its legal obligation, (v) being mandatory for the legitimate interests of the data controller, provided that it does not harm the fundamental rights and freedoms of the data subject, and (vi) protection of public health, preventive medicine, medical diagnosis, treatment and care services, and planning and management of healthcare services and their financing;

  1. a) In compliance with the law and the principles of good faith,
  2. b) Accurately and, where necessary, up to date,
  3. c) For specific, explicit, and legitimate purposes,
  4. d) In a manner that is related to, limited to, and proportionate to the purposes for which they are processed,
  5. e) To be retained for the period stipulated in the relevant legislation or required for the purpose for which they are processed, by automated means, such as camera recordings, or by non-automated means, such as forms filled out by me, provided that they are part of any data recording system; and that they may be processed, recorded, stored, retained, classified, and transferred.

Furthermore, as stated in paragraph 3 of Article 6 of the Law, I know that personal data relating to health and sexual life may be processed without my explicit consent by persons or authorized institutions and organizations under an obligation of confidentiality, solely for the purposes of protecting public health, preventive medicine, medical diagnosis, treatment and care services, and planning and management of healthcare services and their financing.

4.Transfer of Personal Data:

I know that my Personal Data may be transferred, within the framework of the Basic Law on Healthcare Services No. 3359, the Decree Law No. 663 on the Organization and Duties of the Ministry of Health and its Affiliated Institutions, the Public Health Law No. 1593, the Patient Rights Regulation, the Private Hospitals Regulation, the Regulation on the Processing and Protection of Privacy of Personal Health Data, regulations of the Ministry of Health, and the relevant legislation, and for the purposes explained above, to;

  • The Ministry of Health, its affiliated sub-units and centers,
  • The Turkish Medical Association,
  • The Turkish Pharmacists’ Association,
  • The General Directorate of Population and Citizenship Affairs,
  • The General Directorate of Security and other law enforcement authorities,
  • The Social Security Institution,
  • Public prosecutors’ offices, courts, and all judicial authorities as required by legislation,
  • Authorized public institutions and organizations in order to provide information to relevant public officials,
  • Laboratories, healthcare institutions and organizations with which you cooperate for medical diagnosis and treatment, and relevant healthcare institutions and organizations in the event of referral,
  • All private insurance companies with which you work, law firms, financial advisors, business partners, and all consultants, including third parties from whom you receive consultancy services.

5.Your Rights Regarding the Protection of Personal Data:

By approving this Disclosure Text pursuant to the Law and relevant legislation, I have been informed by DR. ARSLAN POLYCLINIC that I have the following rights;

  • To learn whether my personal data is being processed,
  • To request information if my personal data has been processed,
  • To access and request my personal health data,
  • To learn the purpose of processing my personal data and whether it is used in accordance with that purpose,
  • To know the third parties to whom my personal data is transferred domestically or abroad,
  • To request correction if my personal data has been processed incompletely or inaccurately,
  • To request the deletion or destruction of my personal data or its anonymization,
  • To request notification to third parties to whom my personal data has been transferred regarding the correction of incomplete or inaccurate personal data and/or the deletion or destruction of my personal data,
  • To object to any result against me arising from the analysis of my data processed by the Hospital exclusively through automated systems,
  • To request compensation for damages if I suffer damage due to the unlawful processing of my personal data

I HAVE BEEN INFORMED that I possess these RIGHTS by DR. ARSLAN POLYCLINIC.

6.Contact and Application;

I know that I may submit my requests under the Law by completing the “Application Form Pursuant to the Law on the Protection of Personal Data” available at www.drarslanklinik.com;

  • By personally delivering it to Harbiye Mahallesi Abdi İpekçi Caddesi No: 59 Daire: 6 Nişantaşı / Istanbul,
  • By sending it through a notary public,
  • By submitting it in writing to DR. ARSLAN POLYCLINIC at Harbiye Mahallesi Abdi İpekçi Caddesi No: 59 Daire: 6 Nişantaşı / Istanbul with secure electronic or mobile signature, through a registered electronic mail address or my electronic mail address registered in your system, or by using a registered electronic mail address, secure electronic signature, mobile signature, or the electronic mail address previously notified to the data controller by the relevant person and registered in the data controller’s system.
  • I know that I will share with you, as the personal data subject, my personal data to be processed through all contact information I have provided to you, including address, telephone, e-mail address, and other communication channels; that feedback may be provided by you, as the data controller, through the same communication channels; and that, in the event of any change in the relevant contact information, I will inform you as the Data Controller and keep such information up to date.

Conclusion

I declare that I have read and understood the Patient/Service Recipient Disclosure Text within the Scope of the Law on the Protection of Personal Data prepared by DR. ARSLAN POLYCLINIC, and that I have been informed about the purpose of processing my personal data included in this text; the institutions, organizations, companies, and third parties to whom it is transferred; the collection methods and related legal grounds; my rights regarding the protection of my personal data; the security of my personal data; and my right to apply,

Except for cases where the processing and transfer of my Personal Data and Special Categories of Personal Data are required for the performance of a contract, expressly provided for by law, mandatory for DR. ARSLAN POLYCLINIC to fulfill its legal obligations, and necessary for the protection of public health, preventive medicine, execution of medical diagnosis, treatment, and care services, and planning and management of healthcare services and their financing, I hereby CONSENT, in accordance with the matters specified in the Patient/Service Recipient Disclosure Text within the Scope of the Law on the Protection of Personal Data, to the PROCESSING, retention, organization, and transfer of my Personal Data and Special Categories of Personal Data,

WITH MY EXPLICIT CONSENT, I ACCEPT.

PATIENT / SERVICE RECIPIENT

NAME SURNAME

THE STATEMENT “I have read and understood” IN HANDWRITING

SIGNATURE, DATE, TIME

PATIENT/SERVICE RECIPIENT’S RELATIVE, IF ANY

NAME SURNAME

THE STATEMENT “I have read and understood” IN HANDWRITING

SIGNATURE, DATE, TIME

INTERPRETER, IF REQUIRED

NAME SURNAME

DATE, TIME, SIGNATURE