Explicit Consent Form
Medivia Health Group’s Explicit Consent Form records your freely given consent for the processing of your personal data for specific purposes under KVKK.
EXPLICIT CONSENT FORM FOR PROCESSING PERSONAL DATA
Fortis Sağlık Yatırımları A.Ş. (Private Medivia Hospital) and Fortis Tıbbi Hizmetler A.Ş. (Private Medivia Medical Center), under the Law No. 6698 on Protection of Personal Data and the Regulation on Processing and Privacy of Personal Health Data, request your explicit consent for the processing and transfer of your personal data listed in the Patient/Service Recipient Information Text, except for cases required for public health protection, medical diagnosis, examination, treatment, and care services.
1. Collection and Processing of Personal Data:
I have read and understood the Patient/Service Recipient Information Text explaining that my personal data may be collected verbally, in writing, visually, or electronically to provide quality service.
The main personal data collected includes, but is not limited to:
Identity Information: Name, surname, Turkish ID number, driver’s license copy, passport number or temporary ID number, place and date of birth, marital status, gender, insurance or patient protocol number, and other identifiers.
Contact Information: Address, phone, email, call recordings per call center standards, emails, letters, or other communications with the hospital.
Financial Information: Bank account, IBAN, credit card details, billing info.
Security Data: Camera and photo records during hospital visits, license plate info and related images/videos for parking/valet services.
Health Information: All personal health data from diagnosis, examination, treatment, tests, lab results, prescriptions, consent forms for medical interventions.
Other Data: Survey responses, feedback, complaints, website and app usage data including IP address, Wi-Fi info, browser details, medical documents shared voluntarily, and private insurance data.
2. Purposes of Data Processing:
I have been informed that my personal and sensitive data will be processed for the following:
Fulfilling legal obligations under relevant health and data protection laws,
Protecting public health, providing preventive medicine, medical diagnosis, treatment, care, and planning health services and financing,
Providing appointment information, identity verification, billing, and efficient management of services,
Financial reconciliation with contracted institutions,
Responding to requests by public authorities,
Measuring and improving patient satisfaction,
Quality control and service improvement,
Communication about campaigns and other relevant information.
My data may be recorded, stored, classified, and shared with authorized public institutions, health partners, laboratories, insurance companies, legal and financial advisors, and other consultants as necessary.
3. Legal Grounds and Methods of Data Collection:
I acknowledge that my personal data is collected according to laws including Law No. 6698, Health Services Law No. 3359, and relevant regulations. Data will be processed fairly, accurately, transparently, for specific legitimate purposes, limited in scope, and retained only as long as legally required.
Sensitive data about health and sexual life may be processed without explicit consent when required for public health or medical treatment by authorized persons or institutions under confidentiality obligations.
4. Transfer of Personal Data:
My personal data may be transferred to:
Ministry of Health and affiliated bodies,
Turkish Medical Association, Turkish Pharmacists’ Association,
General Directorate of Population,
Law enforcement agencies,
Social Security Institution,
Prosecutor’s office, courts, judicial authorities,
Authorized public bodies,
Health institutions and labs cooperating for diagnosis and treatment,
Private insurance companies, legal offices, financial advisors, partners, and consultants.
5. Rights Regarding Personal Data Protection:
By approving this information text, I understand I have the following rights:
To learn whether my personal data is processed,
To request information if processed,
To access and request my personal health data,
To learn processing purposes and use compliance,
To know third parties receiving my data,
To request correction of inaccurate data,
To request deletion or anonymization,
To request notification of corrections/deletions to third parties,
To object to automated decisions unfavorable to me,
To claim compensation for damages caused by illegal data processing.
6. Communication and Requests:
I can submit my requests through the “Data Subject Application Form” at https://mediviahospital.com.tr/ or:
Deliver in person to:
Güzeltepe Mah. Zübeyde Hanım Cad. No: 15 Çengelköy Üsküdar/İstanbul (Medivia Hospital)
Güzeltepe Mah. Zübeyde Hanım Cad. No: 25/1 Çengelköy Üsküdar/İstanbul (Medivia Medical Center)Send via notary,
Submit securely online with electronic/mobile signature or registered e-mail.
I understand that communication details I provide will be used to process my personal data and to respond to me, and I must update any changes to this information.
Conclusion:
I confirm I have read and understood the Patient/Service Recipient Information Text prepared by Medivia Hospital / Medical Center, including the purposes, legal basis, transfer parties, and my rights regarding personal data.
I explicitly consent to the processing, storage, arrangement, and transfer of my personal and sensitive data beyond the mandatory cases specified by law and the information text.
PATIENT / SERVICE RECIPIENT
Name Surname:
Handwritten note: “I have read and understood”
Signature, Date, Time
IF APPLICABLE — PATIENT / SERVICE RECIPIENT RELATIVE
Name Surname:
Handwritten note: “I have read and understood”
Signature, Date, Time
INTERPRETER (if required)
Name Surname:
Date, Time, Signature