PATIENT EXPLICIT CONSENT FORM
This patient information notice has been prepared by Tülay Akkol Oral and Dental Health Services Trade Ltd. Co. (“Tülay Akkol Oral Health Polyclinic/Company”) in accordance with the Personal Data Protection Law No. 6698 (“PDPL”).
1. Collection, Processing and Purposes of Processing Your Personal Data
a. Collection of Your Personal Data
Your personal data is obtained by our Company in accordance with the PDPL and relevant legislation for the purposes of protecting public health, preventive medicine, carrying out medical diagnosis, treatment and care services, planning and managing healthcare services and their financing, improving the quality of these services, and fulfilling data retention, reporting and information obligations required by public authorities and/or stipulated as exceptions under the law.
Accordingly, depending on the nature of the service provided to you, your personal data is collected and processed verbally, in writing, visually, or electronically for the purposes stated below and in order for Tülay Akkol Oral Health Polyclinic to fully and duly perform its contractual and legal obligations.
Your personal data listed below is collected and processed within the scope of the legal grounds set forth in the PDPL, the Basic Law on Health Services No. 3359, the Decree Law No. 663 on the Organization and Duties of the Ministry of Health and Its Affiliates, the Regulation on Private Healthcare Institutions, the Regulation on Personal Health Data, Ministry of Health regulations and other relevant legislation.
b. Your Processed Personal Data
Within the framework explained above, your personal data and – particularly your personal health data – special categories of personal data are listed below:
- Your identity data such as your name, surname, Turkish ID number; if you are not a Turkish citizen, your passport number or temporary Turkish ID number; copy of your ID; place and date of birth; photograph,
- Your contact data such as address, phone number and email address,
- Your financial data such as bank account number and IBAN number,
- Your health data obtained during the provision of medical diagnosis, treatment and care services, such as laboratory and imaging results, test results, examination data and prescription information submitted for follow-up in your file,
- If you are not a Turkish citizen, your nationality data for invoicing purposes by the accounting department,
- If you are not a Turkish citizen, your transportation data such as flight information for the organization of transportation services by the health tourism and consultancy department,
- Your responses and comments shared for the purpose of evaluating our services,
- Closed-circuit camera recordings taken during your visit to our Company,
- Audio call recordings if you contact our Company,
- Your private health insurance data and Social Security Institution data for the financing and planning of healthcare services,
- Browsing information obtained during your use of our website, IP address, browser information, and medical documents, surveys, form data and location data that you provide with your consent.
c. Purposes of Processing Your Personal Data
Your personal data and special categories of personal data listed above may be processed by our Company for the following purposes:
- Protection of public health, preventive medicine, execution of medical diagnosis, treatment and care services, pharmacy and laboratory services,
- Sharing requested information with the Ministry of Health, the Social Security Institution and other public institutions and organizations in accordance with relevant legislation,
- Fulfillment of legal and regulatory requirements,
- If you are not a Turkish citizen, invoicing for our services by the accounting department,
- If you are not a Turkish citizen, organization of transportation services by the health tourism and consultancy department,
- Financing of your healthcare services and covering examination, diagnosis and treatment expenses by the accounting, health tourism and consultancy departments, and sharing requested information with private insurance companies within the scope of eligibility inquiries,
- Issuing invoices for our services by the accounting department,
- Informing you about your appointment through our Call Center and Digital Channels,
- Verification of your identity by Administrative Services, Healthcare Services and Call Center departments,
- Planning and managing internal operations of the Company,
- Carrying out emergency management processes by the Company,
- Conducting analyses to improve healthcare services by the Patient Rights, Quality and IT departments,
- Performing risk management and quality improvement and evaluation processes by the Patient Rights, Quality and IT departments,
- Providing training to our employees by the Quality department,
- Monitoring and preventing abuse and unauthorized transactions by the IT department,
- Verifying your relationship with contracted institutions by the accounting department,
- Responding to any questions and complaints regarding our healthcare services by the Patient Rights and Call Center departments,
- Taking all necessary technical and administrative measures to ensure data security of Company systems and applications by Company Management and IT departments,
- Measuring, increasing and researching patient satisfaction by the Patient Rights and Quality departments,
- Carrying out education and training activities by educational institutions cooperating with our Company.
The above-mentioned “Your Personal and Special Categories of Data” are stored in physical and electronic archives within Tülay Akkol Oral Health Hospital and external service providers by taking all necessary administrative and technical measures to ensure an appropriate level of security, in strict compliance with legislation.
2. Transfer of Your Personal Data
Your personal data obtained by our Company may be shared within the framework of the Basic Law on Health Services No. 3359, the Decree Law No. 663, the PDPL, the Regulation on Private Healthcare Institutions, the Regulation on Personal Health Data, Ministry of Health regulations and other relevant legislation, and for the purposes explained above, with:
- The Ministry of Health, its affiliated units and family medicine centers,
- The Social Security Institution,
- The General Directorate of Security and other law enforcement agencies,
- The General Directorate of Civil Registration,
- Ziraat and Halk Bank Employees Pension and Assistance Fund Foundation,
- Judicial authorities,
- Private insurance companies (health, pension, life insurance and similar),
- Domestic or international laboratories, medical centers, ambulance services, medical device suppliers and healthcare institutions we cooperate with for medical diagnosis and treatment,
- The healthcare institution to which the patient is referred or applies,
- Your authorized legal representatives, our Company officials and shareholders,
- Third parties from whom we receive consultancy services, including lawyers, tax consultants, accountants and auditors,
- Regulatory and supervisory institutions and official authorities,
- Domestic or international systems and real or legal persons,
- Your employer,
- Our suppliers, support service providers, archive service providers and business partners whose services we utilize or with whom we cooperate (you may obtain more detailed information by submitting a written request to our Company).
In line with the above, I hereby accept, declare and undertake that I give my explicit consent freely and without any influence for the matters marked as “I GIVE CONSENT” below.
I have been informed within the scope of the Personal Data Processing Information Notice regarding the purposes of processing my personal data, the institutions, organizations, companies and healthcare professionals to whom it is transferred, the methods of collection and legal grounds, my rights regarding the protection of my personal data, the ensuring of data security and my right to apply.
I GIVE EXPLICIT CONSENT / I DO NOT GIVE EXPLICIT CONSENT to the processing, transfer and storage of my personal and special categories of personal data, except where processing and transfer are mandatory for the performance of the contract, explicitly stipulated by law, necessary for the establishment, exercise or protection of a right, or for the protection of public health, preventive medicine, medical diagnosis, treatment and care services, and planning and management of healthcare services and their financing by persons under confidentiality obligation or authorized institutions and organizations; and provided that such processing activities are carried out in accordance with the Personal Data Processing Information Notice and under confidentiality commitment by persons not under confidentiality obligation and unauthorized institutions and organizations.
CONSENT
Please write in your own handwriting: “I have read and understood”: …………………………………………………………………………………..
Patient Name Surname……………………………………… Signature:……………… Date: ………./………./……… Time:……..
Patient Relative Name Surname:……………………………………….. Signature:……………… Date: ………./………./……… Time:……..
Degree of Relationship: ………………………………………..
Patient Relative Name Surname:……………………………………….. Signature:……………… Date: ………./………./……… Time:……..
Degree of Relationship: ………………………………………..
Reason for Obtaining Consent from Patient Relative:
Patient is under 19 years of age (Signatures of both parents – mother and father – are required. In case of divorced parents, the signature of the parent with custody is required.)
Lacks legal capacity / does not have decision-making capacity (Signature of guardian or legal representative is required.)
Unconscious
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INTERPRETER (If the patient has language/communication problems)
According to my opinion, the information I translated has been understood by the patient/patient relative.
Name Surname of Interpreter:……………………………………….. Signature: ……………… Date: ………./………./……… Time:……..
