Text of Explicit Consent Approval Form

Information and Explicit Consent Form on the Processing of Personal Data

Except for the cases where your personal data, which are detailed in the Disclosure/Information text on the Processing of Personal Data by Ayşe Sezim ŞAFAK, are processed and transferred to the extent necessary for the execution of the contract, if it is clearly foreseen by the law, if it is mandatory for us to fulfill our legal obligations and for the protection of public health, preventive medicine, medical diagnosis, treatment and care services, planning and management of health services and their financing; we request your explicit consent regarding the following matters;

Collection, Processing and Purposes of Processing of Personal Data

I have been informed by reading the Disclosure/Information text on the Processing of Personal Data that you obtain my personal data verbally, in writing, visually, or electronically from the Call Center, internet, mobile applications, physical locations, and similar channels, depending on the nature of the service provided, in order to provide me with high-standard service. In this context, my general and special personal data obtained, primarily my personal health data required for the execution of all medical diagnosis, examination, treatment and care services and obtained for this purpose, are listed below;

1. My identity data such as my name, surname, Turkish identity number, passport number or temporary Turkish identity number if I am not a Turkish citizen, place and date of birth, marital status, gender information and a photocopy of the Turkish identity card or driver’s license that I have submitted,
2. My communication data such as my address, telephone number, e-mail address,
3. My financial data such as my bank account number, IBAN number,
4. My health and sexual life data obtained during the execution of medical diagnosis, treatment and care services such as my laboratory and imaging results, test results, examination data, prescription information that I have submitted for the purpose of being tracked in my file,
5. The answers and comments I have shared for the purpose of evaluating your services,
6. My closed circuit camera system image and audio recordings taken during my visit to your hospitals,
7. Voice conversation records kept if I contact your call center,
8. My private health insurance data and Social Security Institution data for the purpose of financing and planning health services,
9. Social My visual and audio data obtained with my knowledge for sharing on media platforms and the clinic’s web address,
10. My navigation information obtained during the use of your website and mobile application, my IP address, browser information and medical documents, surveys, form information and location data that I have submitted with my own consent. Protection of public health, preventive medicine, medical diagnosis, treatment and care services,
11. Sharing the requested information with the Ministry of Health and other public institutions and organizations in accordance with the relevant legislation,
12. Fulfilling legal and regulatory requirements,
13. Financing my health services, covering my examination, diagnosis and treatment expenses by the Patient Services, General Accounting, Medical Accounting, Marketing
14. Coordination, Communication Coordination departments, sharing the requested information with private insurance companies within the scope of entitlement inquiry,
15. Being informed about my appointment through the Call Center and Digital Channels,
16. Confirming my identity by the Patient Services, Medical Directorate and Call Center departments,
17. Planning and managing the internal functioning of the institution by Ayşe Sezim ŞAFAK t Management,
18. Conducting analysis for the purpose of developing health services by the Quality, Patient Rights, Patient Services, Information Systems departments,
19. Providing training to your employees by the Human Resources and Quality departments,
20. Monitoring abuse and unauthorized transactions by the Audit and Information Systems departments and prevention,
21. Performance of risk management and quality development activities by Quality, Patient Rights, Patient Services, Information Systems departments,
22. Invoicing for your services by Patient Services, General Accounting, Marketing and Communication departments,
23. Confirmation of my relationship with institutions that have agreements with your hospital by Patient Services, Financial Affairs, Marketing departments,
24. Ayse Sezim ŞAFAK, Patient Services, Patient Rights, Call Center departments, so that all my questions and complaints regarding the health services provided/to be provided to me can be answered,
25. Ayse Sezim ŞAFAK, Information Systems departments, taking all necessary technical and administrative measures within the scope of data security of your hospital’s systems and applications,
26. Marketing, Communication, Call Center departments, participation in campaigns and providing campaign information, designing and communicating special content, tangible and intangible benefits on e-mail, web and mobile channels,
27. Measurement, increase and research of patient satisfaction by Ayşe Sezim ŞAFAK, Patient Rights, Patient Services departments,

The above-mentioned “Personal and Special Data” I have been informed in detail that Ayşe Sezim ŞAFAK can be preserved in physical and electronic archives with great care and in compliance with the provisions of the legislation.

Transfer of Personal Data

My personal data is processed within the framework of the Health Services Fundamental Law No. 3359, the Decree Law No. 663 on the Organization and Duties of the Ministry of Health and its Affiliated Institutions, the Personal Data Protection Law No. 6698, the Private Hospitals Regulation, the Regulation on the Processing and Protection of Privacy of Personal Health Data, the Ministry of Health regulations and other legislation provisions and for the purposes explained above;

1. The Ministry of Health, sub-units of the ministry and family medicine centers,
2. Private insurance companies (health, retirement, life insurance and similar),
3. The Social Security Institution,
4. The General Directorate of Security and other law enforcement agencies,
5. The General Directorate of Population,
6. The Turkish Pharmacists Association,
7. Judicial authorities,
8. Laboratories, medical centers, ambulances, medical devices and health service providers located in Turkey or abroad that you cooperate with as Ayşe Sezim ŞAFAK for medical diagnosis and treatment,
9. Another health institution that I am referred to or that I apply to in case I am referred,
10. Legal representatives that I have authorized,
11. Third parties that you receive consultancy from, including lawyers, tax consultants and auditors that you work with,
12. Regulatory and supervisory institutions and official authorities,
13. In case my invoicing will be made to my employer, with my employer for this purpose,
14. Suppliers, support service providers, archive service providers and business partners that you benefit from or cooperate with as a company (for more detailed information, I know that I can obtain information by applying to our hospital in writing) may be shared with.
15. Method and Legal Reason for Collecting Personal Data

I have been informed that my personal data is being collected and processed in all kinds of verbal, written, visual or electronic media, for the purposes stated above and for all kinds of work within the scope of Ayşe Sezim ŞAFAK’s field of activity to be carried out within the legal framework and for Ayşe Sezim ŞAFAK to fully and properly fulfill its contractual and legal obligations within this scope.

The legal reason for collecting my data is these people;

1. The Law on the Protection of Personal Data No. 6698,
2. The Health Services Fundamental Law No. 3359,
3. The Decree Law No. 663 on the Organization and Duties of the Ministry of Health and its Affiliated Institutions,
4. The Private Hospitals Regulation,
5. The Regulation on the Processing and Protection of Privacy of Personal Health Data,
6. The Ministry of Health regulations and other legislative provisions.

In addition, as stated in Article 6, paragraph 3 of the Law, I know that personal data related to health and sexual life can only be processed by persons or authorized institutions and organizations under a confidentiality obligation without my explicit consent for the purposes of protecting public health, conducting preventive medicine, medical diagnosis, treatment and care services, planning and managing health services and their financing.

Your Rights Regarding the Protection of Personal Data

Pursuant to the law and relevant legislation;

1. To learn whether my personal data has been processed,
2. To request information about my personal data if it has been processed,
3. To access and request my personal health data,
4. To learn the purpose of processing my personal data and whether it is used in accordance with its purpose,
5. To know the third parties to whom my personal data has been transferred domestically or abroad,
6. To request correction of my personal data if it has been processed incompletely or incorrectly,
7. To request deletion or destruction of my personal data,
8. To request notification of the third parties to whom my personal data has been transferred regarding the correction of my personal data if it has been processed incompletely or incorrectly and/or the deletion or destruction of my personal data,
9. To object to the emergence of a result to my detriment by the analysis of my processed data exclusively through automated systems,
10. I have been informed that I have the right to request compensation for the damages if I suffer damages due to the processing of my personal data in violation of the law.

I know that I can submit my requests within the scope of the law by filling out the “Personal Data Protection Law” Application Form on the “www.draysesezim.com” web address;

1. I can personally deliver it to the “COMPANY ADDRESS” address,
2. I can send it through a notary,
3. I can send it to the info@draysesezim.com information address with secure electronic or mobile signature, via my registered electronic mail address or my electronic e-mail address registered in your system.

I have read and understood the Disclosure/Information text on the Processing of Personal Data prepared by Ayşe Sezim ŞAFAK,

I have been informed about the purposes of processing my personal data, the institution, organization, company and Medical Directorate to which it is transferred, the collection methods and legal reasons, my rights regarding the protection of my personal data, data security and my right to apply, My personal and special data; to store, process and transfer in accordance with the matters specified in the Disclosure/Information text on the Processing of Personal Data, except for the execution of the contract, if it is clearly foreseen by law, if it is necessary for Ayşe Sezim ŞAFAK to fulfill its legal obligations and if it is processed and transferred to the extent necessary for the protection of public health, preventive medicine, medical diagnosis, treatment and care services, planning and management of health services and their financing,

I ACCEPT with my EXPLICIT CONSENT.

*According to the Patient Rights Regulation; 1 copy of the form will be given to you. If the form is not given to you, please notify. ONAM 4 Write “I understand what I read” in your own handwriting:……………………………………………………………………………………… Patient Name Surname:…………………………………………………………………….. Signature:…………………………………………….. History: / / Hour: …….. / …….

Degree of Relation:

Reason for Obtaining Consent from the Patient’s Relative:

• The patient is under 19 years of age (Signatures are obtained from both parents – mother and father. However, if the family is divorced, the signature is obtained from the parent with custody)
• Not having the power of appeal/not having the ability to make decisions (Signature is obtained from the guardian or legal representative)
• UNCONSCIOUS INTERPRETER (If the patient has a Language/Communication Problem) In my opinion, the information I translated has been understood by the patient/relative.

Name and Surname of the Translator: ……………………………………………………Signature: ……………………………………………..

History: …./ ….. / …………… Hour: …….. / ……. Degree of Closeness: …………………………………………………………………