DATA SUBJECT APPLICATION FORM
(Pursuant to Law No. 6698 on the Protection of Personal Data)
GENERAL INFORMATION:
Under Law No. 6698 on the Protection of Personal Data (“Law”), individuals whose personal data are processed (referred to as “Data Subject”) are granted certain rights under Article 11. To exercise these rights, they must submit a request to the Data Controller.
Pursuant to Article 13, paragraph 1 of the Law, applications regarding these rights must be submitted to Op. Dr. Fatih TURAN ENT Clinic as the Data Controller, in writing, via e-mail, or through other methods determined by the Personal Data Protection Board (“Board”).
APPLICATION METHODS:
You may submit your application to our Clinic through one of the following methods:
i. By personally submitting a completed and signed hard copy of this Application Form, along with an identity document, to the address:
İstiklal Mh. Safrancık Sk. No:21 D:1/A Serdivan/Sakarya
ii. By sending a completed and signed hard copy of this Application Form, along with an identity document, via notary to the address above.
iii. By signing this Application Form with a "secure electronic signature" as defined in Law No. 5070 on Electronic Signatures and sending it to:
opdrfatihturan@gmail.com
iv. By signing and scanning a completed hard copy of this Application Form and sending it as an attachment via e-mail to:
opdrfatihturan@gmail.com
(If this method is used, a scanned copy of an identity document must also be attached.)
These methods constitute “written application channels” under Article 13/1 of the Law. If additional application methods are announced by the Board, our Clinic will also make announcements accordingly.
Applications submitted to us will be responded to as soon as possible and within thirty (30) days at the latest, depending on the nature of the request, in accordance with Article 13/2 of the Law. Applications are generally free of charge. However, if the response to your application incurs a cost, a processing fee may be charged in accordance with Article 7 of the “Communiqué on Principles and Procedures for the Application to the Data Controller”.
To properly evaluate your request, please ensure that all requested information and documents are provided completely and accurately. Failure to provide complete and accurate information may result in delays or difficulties in evaluating your request. In such cases, the Clinic reserves its legal rights.
APPLICANT IDENTIFICATION AND CONTACT INFORMATION
To identify the applicant and process your request appropriately, the following information must be provided:
Full Name:
National ID Number:
E-mail Address (if you request a response via e-mail):
Address (if you request a response by post):
Mobile Phone:
Our Clinic may contact you to verify your identity after your request is received. If required information or documents are missing, we will request them from you. If not provided, a response explaining the issue will be sent within thirty (30) days.
PLEASE INDICATE YOUR RELATIONSHIP WITH OUR CLINIC:
☐ Patient / Legal Guardian / Representative
☐ Visitor
☐ Employee
☐ Other: ……………………………
Contact Person / Department within Clinic: ………………………………………
Subject: ……………………………………………………………………………………
☐ Former Employee – Years Worked: ……………
☐ Other: …………………………………………
☐ Job Applicant – Date: ……………
☐ Third Party Company Employee – Company and Position: …………………………………
☐ Patient / Guardian – Years Treated: ……………
☐ Other – Method of Data Sharing: ……………………………
Date: ……………
PREFERRED METHOD FOR RECEIVING OUR RESPONSE:
☐ Send to my postal address
☐ Send to my e-mail or KEP (Registered Email) address
☐ I will collect it in person
(In case of proxy collection, a notarized power of attorney is required.)
REQUEST TABLE
| No | Subject of Request | Your Selection |
|---|---|---|
| 1 | I want to learn whether your clinic processes personal data about me. (Art. 11/1-a) | ☐ |
| 2 | If my personal data is being processed, I request information regarding these activities. (Art. 11/1-b) | ☐ |
| 3 | I want to learn the purpose of processing and whether it is used in accordance with that purpose. (Art. 11/1-c) | ☐ |
| 4 | If my data is transferred to third parties domestically or abroad, I want to know who these third parties are. (Art. 11/1-ç) | ☐ |
| 5 | I believe my data is incorrect/incomplete and request correction. Please indicate the incorrect data below and attach supporting documents. (Art. 11/1-d) | ☐ Incorrect Data: …………… |
| 6 | Although processed lawfully, I believe the purpose no longer exists and request: (Only one option must be selected) | |
| a) Deletion ☐ | ||
| b) Anonymization ☐ | ||
| c) Destruction ☐ | ||
| (Art. 11/1-e) | ||
| 7 | I request that my corrected data (Request 5) also be corrected with third parties. Please provide supporting documents. (Art. 11/1-f) | ☐ Incorrect Data: …………… |
| 8 | I request that the deletion/anonymization processes be notified to third parties to whom the data was transferred. (Art. 11/1-f) | ☐ |
| 9 | I object to results obtained through automated processing that negatively affect me. Please specify the data and provide documents. (Art. 11/1-g) | ☐ Analysis & Negative Impact: …………… |
| 10 | I suffered damage due to unlawful processing of my personal data and request compensation. Please indicate the violation and provide documents. (Art. 11/1-h) | ☐ Violation Details: …………… |
PLEASE CLARIFY YOUR REQUEST IN DETAIL:
(If the table above is insufficient for your request, please use this section.)
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
I hereby request that my application be evaluated and answered through the method I have selected, based on the information and requests I have specified above.
Date:
Signature: ______________________