Data Subject Application Form

DATA SUBJECT APPLICATION FORM

As Op. Dr. Serpil Kırım, we would like to state that you have rights specified in Article 11 of the Personal Data Protection Law No. 6698 (“Law“) and granted to data subjects. Op. Dr. Serpil Kırım, who is the data controller pursuant to Article 13 of the Law, has published the Clarification Text on the Protection of Personal Data on the website http://www.drserpilkirim.com/ regarding the conditions of processing personal data, data security and destruction procedures and principles.

As a data subject, you can send us your requests regarding personal data within the scope of Article 13 of the Law and Article 5 of the Communiqué on the Procedures and Principles of Application to the Data Controller by using this Data Subject Application Form (“Application Form“).

DATA SUBJECT RELATED PERSON RIGHTS

As a data subject, the rights granted to you by the Law are as follows, and you can submit your requests to us in writing and in Turkish by using the application method shown in this Application Form.

You can make the following requests with the Application Form:

1. Learn whether your personal data is being processed,
2. Request information if your personal data has been processed,
3. To learn the purpose of processing your personal data and whether they are used in accordance with their purpose,
4. To know the third parties to whom personal data are transferred domestically or abroad,
5. To request correction of personal data in case of incomplete or incorrect processing,
6. To request the deletion or destruction of personal data processed in accordance with the law and legislation in the event that the reasons requiring the processing of personal data disappear,
7. To request notification of the transactions made pursuant to subparagraphs (e) and (f) to third parties to whom personal data are transferred,
8. To object to the emergence of a result to the detriment of the person himself/herself by analyzing the processed data exclusively through automated systems,
9. In case of damage due to the processing of personal data in violation of the Law, to demand the compensation of the damage.

APPLICATION WAY

The applications to be made to Op. Dr. Serpil Kırım, who is the data controller pursuant to Articles 11 and 13 of the Law, shall be made by printing out this form at http://www.drserpilkirim.com/:

• In writing to Barbaros Hayrettin Paşa Mahallesi 1992 Sokak Vetro City No:16 Kat:1 Daire:34 Esenyurt-İstanbul with a wet signed petition or through a notary public,

or

• It will be made by using your registered e-mail (KEP) address or secure electronic signature, mobile signature or your e-mail address previously notified by you to Op. Dr. Serpil Kırım and registered in our data recording system and sent to [email protected] e-mail address.

 

1. Applicant Contact Person Information

Applicant
Name
Surname
T.C. Identity Number
Passport Number if the Applicant is a Foreigner
Residential/Workplace Address
Telephone and Fax Number
Electronic Mail Address

1. Relationship between the Applicant and Op. Dr. Serpil Kırım
2. Please indicate your relationship with Dr. Serpil Kırım (patient, patient relative, visitor, prospective employee, former employee, business partner, third party company employee, etc.).

☐ Hasta	☐ Hasta yakını
☐ Ziyaretçi	☐ Tedarikçi
☐ Eski Çalışan Çalışılan Yıllar:	☐ İş Başvurusunda Bulunan/Özgeçmiş Paylaşan Kişi Tarih:
☐ Üçüncü Kişi Firma Çalışanı Çalışılan firma ve pozisyon bilgisi:	☐ Diğer:
The unit you contacted under Op. Dr. Serpil Kırım:     Subject:

 

1. Demand

Please write your request regarding your application.

 

 

 

 

 

 

ANNEXES (Please list below the additional documents related to your application, if any)

1. Application Response

Please select the way in which your application will be responded to.

☐ I want it sent to my residential/work address.

☐ I want it sent to my e-mail address.

☐ I want to receive it by hand (Without a power of attorney, the application answer is not given on behalf of someone else. For hand delivery, it must be received from Op. Dr. Serpil Kırım within the legal response period. Otherwise, no responsibility will be accepted).

• Written applications are deemed to have been made on the date the document is notified to the data controller Op. Dr. Serpil Kırım and/or her representative; applications made by other methods are deemed to have been made on the date the application reaches the data controller.
• The reply regarding your application will be sent to the address you have chosen within 30 (thirty) days at the latest from the notification of the request.
• If you request the answer to your application in written form, your application is finalized free of charge up to 10 pages. For answers over 10 pages, a fee is charged for each page exceeding the tariff determined by the Personal Data Protection Authority.

We inform you that we reserve the right to request additional documents in order to determine your personal data processed by Op. Dr. Serpil Kırım regarding your application and to respond to your application accurately and completely. We are not responsible for any errors and damages that may arise due to incorrect, incomplete or outdated information you have provided.

Applicant (Personal Data Subject)

Name Surname:

Application Date :

Signature :