Protection of Personal Data

CONSENT FORM WITH REGARD TO PROCESSING OF PERSONAL DATA

We are hereby requesting your explicit consent with regard to the following issues, except for and other than the processing and disclosure by Acıbadem Sağlık Hizmetleri ve Tic. A.Ş. (“Acıbadem/Hospital”) of your personal data as detailed in the “Consent Form with Regard to Processing of Personal Data” if and to the extent needed for performance of the underlying contract, and protection of public health, and provision of preventive medicine, medical diagnosis, treatment and maintenance services, and planning and management of healthcare services and financing:

· I hereby certify that it is within my knowledge that my past-dated personal data relating to the period of time prior to the insurance policy date, and my special personal data, and my personal healthcare data may be required to be shared with my private insurance firm or with intermediary institutions duly authorized by my private insurance firm, if and when my private insurance firm or intermediary institutions duly authorized by my private insurance firm wish and need to have access to my medical data and information, and/or in the course of authorization and billing processes for healthcare services received by me from Acıbadem, or at the time of issuance of insurance policy for me, and that disclosure of my personal health information to my private insurance firm is imperative and essential for use of benefits of private health insurance by me and for payment or reimbursement of my medical treatment expenses, and to this end, my patient file and my other personal healthcare data, including, but not limited to, external healthcare institution analyses and reports, may occasionally be required to be disclosed by Acıbadem to my private insurance firm or to intermediary institutions duly authorized by my private insurance firm, and also that pursuant to and in accordance with the Patient Rights Regulation, the Private Hospitals Regulation and other relevant applicable laws and regulations, my physical / digital patient file, and my personal data contained in protocol books kept in medical service units, and my other personal healthcare data, including, but not limited to, external healthcare institution analyses and reports, and invoices of healthcare services received for medical diagnosis and treatment purposes may be disclosed or transferred to archiving companies contracted by Acıbadem for archiving and destruction purposes, or to contracted firms and business partners paying my medical treatment expenses; and

· That for the sake of provision of medical diagnosis, treatment and maintenance services to me, my personal healthcare data and information may be disclosed and transferred support service providers used and contracted by Acıbadem, such as laboratories, meal companies, ambulances, and suppliers engaged in maintenance and repair of medical devices; and

· That my personal data processed and recorded in Acıbadem applications for the sake of planning and management of medical diagnosis, treatment and maintenance services, and healthcare services of me, may be disclosed and transferred to Acıbadem’s systems for safe and secure storage and operations purposes, or to other service providers keeping back-ups of the relevant systems at home or abroad and acting in compliance with information security standards; and

· I am also cognizant of the fact that if my employer has a contract with Acıbadem, the invoice containing my personal healthcare data and my all medical records are absolutely required to be shared with my employer for payment or reimbursement by my employer of the fees of healthcare services received by me if and to the extent my healthcare services are subject to prior approval of my employer or the cost of my healthcare service is paid or reimbursed by my employer, and accordingly, my personal healthcare data and information may be disclosed and transferred by Acıbadem to my employer; and

· That if and when I receive any healthcare services from any business unit of the Hospital, for confirmation of accuracy of my patient clinic and treatment information, and for quality control of treatment services by other specialized doctors, my identity data, visual data and healthcare data may be disclosed and transferred to other third parties working in cooperation with Acıbadem therein; and

· That in case of opinion or second opinion requests transmitted by an intermediary institution in my name to Acıbadem’s internet websites, the opinions also containing my healthcare data and information to be given by the Hospital may be disclosed and transferred to that intermediary institution; and

· That my personal data may be processed, and you may be contacted, for the purposes of reminder and information about your appointments, and information about new medical developments and new healthcare services, by contacting you by telephone, SMS, electronic mail and other communication means.

I, the undersigned, hereby declare and acknowledge that this “Consent Form With Regard to Processing of Personal Data”, comprised of two pages, is delivered to me and fully clarified to me, and that I have read, reviewed, evaluated and understood the aforesaid information pertaining to processing, disclosure and transfer by ACIBADEM of all kinds of my personal data provided to ACIBADEM, and that I give my EXPLICIT CONSENT to the processing, storage, and disclosure to third parties of my special personal data and my personal healthcare data and information, particularly my personal data, in accordance with the procedures and principles set forth hereinabove, pursuant to and under the Law on Processing of Personal Data, and that I know my rights granted to and vested in me by the laws, and I have read and understood this document, and accordingly, I hereby give my consent and approval for processing by ACIBADEM of my personal data, personal healthcare data and special personal data and information covered by the information notes cited above, and for sharing of such data and information by ACIBADEM with third parties, especially ACIBADEM Group Companies, for the purposes and intentions cited hereinabove.

For detailed information in connection herewith, you may visit the address of İnformation About Using Personal Data .