Data Subject Application Form
Application Form for Data Subjects
This Application Form has been prepared by Fortis Sağlık Yatırımları A.Ş. (Private Medivia Hospital) and Fortis Tıbbi Hizmetler A.Ş. (Private Medivia Medical Center), as Data Controllers, to promptly evaluate and resolve applications made by data subjects pursuant to Articles 11 and 13 of the Law No. 6698 on the Protection of Personal Data (“Law”) and Article 5 of the Communiqué on the Procedures and Principles of Application to the Data Controller (“Communiqué”).
APPLICATION METHOD
As a data subject, you can submit your requests regarding your rights under the Law to Fortis Sağlık Yatırımları A.Ş. (Private Medivia Hospital) and Fortis Tıbbi Hizmetler A.Ş. (Private Medivia Medical Center) by completing this Application Form and sending it via:
Written application with your wet signature delivered in person to:
Güzeltepe Mah. Zübeyde Hanım Cad. No: 15 Çengelköy/Üsküdar (Medivia Hospital)
Güzeltepe Mah. Zübeyde Hanım Cad. No: 25/1 Çengelköy/Üsküdar (Medivia Medical Center)Notary public,
Or electronically via https://mediviahospital.com.tr/ using a secure electronic signature, mobile signature, or the email address previously registered in the data controller’s system and notified by the relevant person.
INFORMATION ABOUT THE DATA SUBJECT
Applicant’s Contact Information
Full Name*:
Turkish ID Number*:
Address*:
Phone Number* and/or Fax Number:
Email Address*:
(*) Mandatory fields.
The personal data you provide above will be processed solely for evaluating and concluding this Application Form and contacting you.
RELATIONSHIP OF THE APPLICANT TO OUR INSTITUTION/COMPANY/HOSPITAL
(Please mark X where appropriate and explain if needed)
Employee
Former Employee
Customer
Business Partner
Visitor
Other:
REQUESTS OF THE DATA SUBJECT
| Your Request | Required Information/Document | Select (X) |
|---|---|---|
| 1. I want to learn whether my personal data is processed by … | If you want to get information about a special category of data, please specify. | ( ) |
| 2. I want to know the purpose of processing of my personal data by … | If you want to get information about a special category of data, please specify. | ( ) |
| 3. I want to know whether my personal data is used appropriately by … | If you want to get information about a special category of data, please specify. | ( ) |
| 4. If my personal data is transferred to third parties domestically or abroad, I want to know these third parties. | If you want to get information about a special category of data, please specify. | ( ) |
| 5. I think my personal data is incomplete or incorrect, and I want it to be corrected. | Please specify the incomplete or incorrect data and the correct data. | ( ) |
| 6. I want my personal data corrected and/or deleted also to be notified to the third parties to whom my data has been transferred. | Please specify the incomplete or incorrect data and the correct data. | ( ) |
| 7. I want my personal data deleted or anonymized as the reasons requiring processing no longer exist. | Please specify which data and the adverse results you believe. Attach supporting documents if any. | ( ) |
| 8. I want my personal data deleted or anonymized also by the third parties to whom my data has been transferred as the reasons requiring processing no longer exist. | Please specify which data this applies to and reasons with supporting documents. | ( ) |
| 9. I believe that my personal data processed by … is analyzed solely by automated systems, leading to an outcome against me. I object to this. | Please specify reasons and any supporting documents. | ( ) |
| 10. I demand compensation for damages due to unlawful processing of my personal data. | Please specify the reasons and the damages you suffered with supporting documents such as Board or court decisions. | ( ) |
If applications are made by third parties on behalf of the data subject, a notarized power of attorney must be attached. Applications on behalf of minors under custody require documentation of custody.
To ensure data security, upon receiving your request, Medivia Hospital/Medical Center may contact you to verify your identity and request additional documents. These documents will be destroyed after verification.
If the information or documents are incomplete, Medivia Hospital/Medical Center will ask you to complete them. The evaluation period of 30 days under Article 13/2 of the Law will be suspended until all documents are received.
FINALIZATION OF THE DATA SUBJECT’S REQUEST
Your request will be answered as soon as possible and within 30 days at the latest from the date it reaches us, in accordance with Article 13 of the Law. The response will be provided in writing or electronically according to your choice below:
I want the result sent to my email address. ( )
I want the result sent by postal mail to my address. ( )
I want the result sent by fax. ( )
DATA SUBJECT DECLARATION
I request that my application for information about my rights under the Law be evaluated and concluded in accordance with the requests I indicated above. I declare that the information and documents I provided are accurate, up-to-date, and belong to me.
Data Subject’s Name-Surname:
Signature: