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Explicit consent text for the processing of personal data of patients and patients 'relatives

EXPLICIT CONSENT TEXT FOR THE PROCESSING OF PERSONAL DATA OF PATIENTS AND PATIENTS 'RELATIVES

I have read the Clarification Text for the Processing of Personal Data of Patient and Patient’s Relatives, and within this scope;

I hereby express my consent to the collection, recording, processing, storage and transfer of my personal data within the framework of the principles of the law by the data controller Dr. Hande Ulusal Dermatoloji Klinik Tic.Ltd.Şti. and the data opeators, the insured employees of Dr. Hande Ulusal Dermatoloji Klinik Tic.Ltd.Şti.; and I agree, declare and undertake their transfer in a way specified below.

In accordance with the “Turkish Personal Data Protection Law” no. 6698 and the “Regulation on Processing Personal Health Data and Protecting its Privacy,” I hereby accept, declare and undertake that I consent to the processing, storage and transfer of my personal data, sensitive personal data, health data, any personal data including those that determine or serve to determine my identity, given by me verbally/in writing and/or electronically, which are detailed below, by Dr. Hande Ulusal Dermatoloji Klinik Tic.Ltd.Şti. within the scope of the “Turkish Personal Data Protection Law” no. 6698 and the “Regulation on Processing Personal Health Data and Protecting its Privacy.”
Data clearly belonging to an identified or identifiable natural person, processed partially or as a whole automatically or non-automatically as part of the data recording system, containing information about the identity of the person, in the form of documents such as driver’s license, identity card and passport that contain information such as name-surname, T.C.ID number, nationality information, parents’ name, place of birth, date of birth, gender, as well as tax number, SSI number, signature, etc.
Data clearly belonging to an identified or identifiable natural person, processed partially or as a whole automatically or non-automatically as part of the data recording system, such as phone number, address, e-mail address, fax number, IP address.
Data clearly belonging to an identified or identifiable natural person, processed partially or as a whole automatically or non-automatically as part of the data recording system, such as personal data regarding the records and documents, video recordings, and fingerprint recordings created while entering the physical space and staying inside, as well as records created at the security point.
Data clearly belonging to an identified or identifiable natural person, such as photo and video recordings (excluding records within the scope of Physical Space Security Information), and data contained in documents that are copies of documents containing personal data.
Data clearly belonging to an identified or identifiable natural person, processed partially or as a whole automatically or non-automatically as part of the data recording system, which are specified in Article 6 of the Turkish Personal Data Protection Law (e.g. health data including blood groups, biometric data, etc.)

Having been fully informed by Dr. Hande Ulusal Dermatoloji Klinik Tic.Ltd.Şti about how the personal data belonging to me and to those who are dependent on me would be processed within the aforementioned scope;
I know that my personal and sensitive personal data will be processed and it will be transferred to the Ministry of Health, institutions and organizations affiliated to the Ministry of Health, private information management systems, and management systems affiliated to the Ministry of Health. In addition, with intent to allow for creation and follow-up of appointments, planning and management of health services and their financing, performance of storage and archive activities, follow-up of requests/complaints, conduct of medical diagnosis, treatment and care services, and provision of information to authorized persons, institutions and organizations;

1-For the collection, recording, processing, storage and transfer of my above-mentioned personal and sensitive personal data within the framework of the principles of the law by Dr. Hande Ulusal Dermatoloji Klinik Tic.Ltd.Şti. and the data operators, the insured employees of Dr. Hande Ulusal Dermatoloji Klinik Tic.Ltd.Şti.,

I give consent.                                                          I do not give consent.

2-For the transfer of my identity information and visual and health data to health institutions and organizations in Turkey or abroad that provide expert opinion as a second opinion on the diagnosis and treatment of my health condition,

I give consent.                                                           I do not give consent.


3-For the transfer of my identity information and visual and health data to health institutions and organizations in Turkey or abroad that provide expert opinion as a second opinion on the diagnosis and treatment of my health condition,

I give consent.                                                            I do not give consent.


4- For the transfer of my personal health data by Dr. Hande Ulusal and the data operators, the insured employees of Dr. Hande Ulusal Dermatoloji Klinik Tic.Ltd.Şti. to my private insurance company, supplementary health insurance company or to an intermediary firm authorized by my private insurance company, having know that it is compulsory to transfer my personal health data to private insurance companies, supplementary health insurance companies, and contracted institutions to enable me to benefit from private and supplementary health insurance and allow for the payment of my costs, when my private insurance company or an intermediary firm authorized by my private insurance company, supplementary health insurance companies, and contracted institutions want to access my health information and/or in the provision and invoicing process of health services that I receive from your outpatient clinic/doctor’s office,

I give consent                                                             I do not give consent.


5-For the processing of my personal data shared above, as well as my medical photos to be taken by the physician during the procedure; for the photography or video recording during the intervention/treatment to be performed on me and for their storage and processing,

I give consent I do not give consent.

6-For the notification of my appointment and campaign information via e-mail, social media or tools such as SMS, and for the sharing of my financial information with notifications to my e-mail address:……………………………………………………,

I give consent                                                             I do not give consent.

7- For the transfer of my data to health institutions based abroad, from which consultation/laboratory services are received, and to physicians and medical staff, limited to the provision of the medical consultation/examination/test if I consent to the performance of consultations/ examinations /tests.

I give consent                                                              I do not give consent.

Explicit Consent for the Transfer of Sensitive Personal Data to the Family Members of the Patient, and Other Persons Approved by the Patient

For the transfer of my health data (e.g. test results, examination information, appointment information, general information about my state of health)in accordance with the provisions of the “Turkish Personal Data Protection Law” no. 6698 and the “Regulation on Processing Personal Health Data and Protecting its Privacy” to my family members/relatives, accompanists, deputies or legal representatives and other third parties that I have authorized listed below in cases where the transfer of such data is a medical necessity or mandatory by court order (e.g. T.R. Ministry of Health, T.R. Social Security Institution, courts, organizations to which patient referrals / transplantation are made, companies engaged in hospital/patient information management systems),

Name and Surname
Relationship to Patient
T.R. ID. No No.
Contact Information

(Information about family members, accompanists and other third parties authorized by the Patient for the transfer of sensitive personal data is filled in above by the patient)

I give consent                                                              I do not give consent.

 

*** I hereby accept, declare and undertake that I have given the sensitive personal information about my family members, relatives and other third parties to your clinic, in accordance with the “Turkish Personal Data Protection Law” no. 6698 and the the relevant Regulations; and in this context, I have informed the relevant persons and obtained their consent when needed.


Patient / Patient's Legal Representative / Patient's Guardian / Parents of Child Patients

Name and Surname :


Relationship to Patient
(This section should be filled in by a person other than the patient specified above.)

Date: 

Signature :

**** Name and Surname of the translator / witness if translator / witness is required ……………………………………………………………