Dear Applicant,

Article 11 of Law on the Protection of Personal Data No. 6698 grants data subjects who are defined as the “relevant person” the right to make certain requests regarding the processing of personal data. This application form was arranged to determine the type of relationship you have with our clinic and whether you have any personal data processed by us, for you to inform us of your rights arising from the Law on the Protection of Personal Data, and for us to provide a correct and complete response to your application within the legal period.

Within the scope of the procedures regarding your applications, we reserve the right to demand additional information and documents (identity card, driver's license, other documents that can be used as official identity cards, power of attorney, etc.) to prevent legal risks that may arise from illegal and unfair data sharing and to ensure the security of your personal data. We shall not be responsible for any incorrect or out-of-date information related to your request submitted to us with this application form or any unauthorized application. Your application will be concluded free of charge, but you may be charged according to a tariff to be determined by the Board as per Articles 6/f.5 and 7 of the Communiqué on Procedures and Principles for Application to a Data Controller if any cost may arise as a result of the process.

You may find the methods for submitting your applications to us, the addresses to which the applications can be submitted, the deadlines for the conclusion of the applications, and the procedures to be followed in the “Information Regarding the Applications on the Protection and Processing of Personal Data” section on our website. We kindly ask you to submit your written requests by one of the methods specified in the above text by filling in this Application Form.

1. Please fill in the required information regarding the applicant.

Name / Surname
Turkish Identity Number (for foreigners, passport number or identification number, if any)
Phone No.
Registered Electronic Mail or Email address (this field is mandatory if you are going to apply with an email)
Address

 

 

2. Please specify your relationship with our workplace.

• Patient / Potential Patient
• Employee / Former Employee
• Potential Employee
• Business Partner
• Employee of Third-Party Company
• Visitor
• Other

 

………………………………………………………………..

The person/unit you are in contact with in our clinic:
The date you received service or contacted (for patients and former patients):
Employment period (for former employees):
The company you work for and your position (for business partners and employees of third party companies):
The date you visited our clinic (for visitors)
Reason (for your relationship with our practice):

 

3. Please mark your request.

Request No.	Subject of the Request	Legal Basis:	Your Choice
1	I would like to learn whether your company processes my personal data.	Law on the Protection of Personal Data, Article 11/1 (a)
2	If you process my personal data, I request information about such data processing activities.	Law on the Protection of Personal Data, Article 11/1 (b)
3	If you process my personal data, I would like to learn the purpose of processing and whether it is used in accordance with this purpose.	Law on the Protection of Personal Data, Article 11/1 (c)
4	If my personal data has been transferred to any third party at home or abroad, I would like to know the identity of such third parties	Law on the Protection of Personal Data, Article 11/1 (ç)
5	I believe my personal data has been processed incompletely or inaccurately, and I request the correction thereof.	Law on the Protection of Personal Data, Article 11/1 (d)
6	Although my personal data has been processed in accordance with the law and the provisions of other relevant laws, I think that the reasons for such processing have ceased to exist, and, in this context, I request that my personal data be deleted or destroyed.	Law on the Protection of Personal Data, Article 11/1 (e)
7	I also want my personal data, which I believe have been processed incompletely or incorrectly, to be corrected by the third parties to whom such data has been transferred.	Law on the Protection of Personal Data, Article 11/1 (f)
8	Although my personal data has been processed in accordance with the law and the provisions of other relevant laws, I believe the reasons for such processing are no longer relevant, and in line with that, I request that the third parties to whom such data was transferred be informed about my request of deletion or destruction of my personal data.	Law on the Protection of Personal Data, Article 11/1 (f)
9	I believe that my personal data processed by your company have been analyzed exclusively through automated systems, and, as a result of this analysis, an adverse outcome has arisen against me. I object to this outcome.	Law on the Protection of Personal Data, Article 11/1 (g)
10	I have incurred damages due to the unlawful processing of my personal data. I claim to be indemnified for these damages.	Law on the Protection of Personal Data, Article 11/1 (h)
11	Other - Specify:

 

4. Please select the type of communication by which you want to receive our response to your application.

• I want it to be sent to my address.
• I want it to be sent to my email address.

(If you choose the email method, we can respond to you faster.)

• I want it to be delivered to me in person.

(In the case of receipt by proxy, there must be a notarized power-of-attorney or certificate of authorization.)

1. Applicant’s Statement

In line with the information I have given above and the requests I have submitted, I kindly ask you to evaluate my application in accordance with Article 13 of the Law on the Protection of Personal Data and the provisions of the relevant Communiqué and inform me about its result.

Within the scope of this application, I confirm and undertake that the information and documents I have provided to you are correct and up-to-date and belong to me and that I have been informed that the information and documents I have provided with this application may be processed by you, limited to the purposes of evaluating and responding to my application and sending the results to me, and determining my identity and address for that purpose as per Article 13 of the Law on Protection of Personal Data No. 6698, that I may request additional information/documents and that I was informed that, if necessary, I may have to pay a certain fee at the tariff determined by the Personal Data Protection Board.

 

Details of Person Making the Application on Behalf of Applicant / Data Subject;

 

Full Name   :

Application Date  :

Signature             :

 

 

 

 

IMPORTANT NOTE: If you are applying on behalf of another person who is a personal data subject, annex the documents (document showing that you are the parent or guardian of the personal data subject, power of attorney, etc.) issued or approved by the competent authorities and showing that you are authorized to apply to your application.

Data Controller

Berat Bora Ok (M.D./Surgeon)

Fenerbahçe Mah. Lalezar Sk. No:7/9, 34726 Kadıköy / Istanbul

Phone: 0216 358 21 22

Website: www.drboraok.com

Email: This email address is being protected from spambots. You need JavaScript enabled to view it.