Relevant Person Application Form

***You can make your application(s) regarding your info within the Personal Data Protection Law (PDPL) by copying and filling the form here and sending it to us.


Relevant Person ApplIcatIon Form

This application form has been prepared by DR HAKAN ERBİL ÜMİTKÖY CLINIC (hereinafter referred to as the “Polyclinic”). Article 13 of the Law on Protection of Personal Data No. 6698 and Communication on Application Procedures and Principles to Data Responsible. It is used for the “application to be made to the data responsible”.

Depending on the nature of the request, the applicant will be answered as soon as possible and within thirty days at the latest.


A. Way/Method of Application

You can make your application by filling out this form, by submitting a different written text other than this form, or by any method determined by the Personal Data Protection Board and in the following ways:

Our clinic;

  • Ümit Mahallesi. 2494/1. Sokak. No: 6, 06810 Çankaya/Ankara to address personally, by mail or courier,
  • To the “[email protected] e-mail address of our polyclinic (by scanning the signed copy of this form)


B. Information of the Relevant Person

Name and Surname
TC/Foreign Identification Number
Contact Info
Phone Number


C. Demand

Please explain in detail your request under the Law on Protection of Personal Data No. 6698 and the personal data subject to your request.

Requests Regarding Processed Personal Data Other
Explanation; Explanation;









D. Appendices

If there is any document that you want to show as a basis for your application to our polyclinic, please write it here and attach it to your application.


Documents to be attached;




E. Transmission of The Request Result

Please tick the communication channel that you want the result of your request to be delivered to you.


Send the result to my address
Send result to my e-mail account
Send the result to my KEP address (please notify if any)


This application form has been prepared in order to determine your relationship with the “clinic” and to fully determine your personal data, if any, and to respond to your application in a correct and legal time. In order to eliminate the legal risks that may arise from illegal and unfair data sharing, and especially to ensure the security of your personal data, the “clinic” reserves the right to request additional documents and information (copy of identity card or driver’s license, etc.) for identification and authorization. In the event that the information regarding your requests you submit within the scope of the form is not correct and up-to-date, or an unauthorized application is made, the “Polyclinic” does not accept any responsibility for such false information or requests arising from unauthorized applications.


F. Relevant Person Application Statement

I request that the application I have made pursuant to the Law on Protection of Personal Data No. 6698 be evaluated and finalized within the framework of the above-mentioned request/requests, I accept, declare and undertake that the information and documents I have provided to you in this “Application to Data Responsible” are correct, up-to-date and belong to me.


Name and Surname    :

Application Date        :

Signature                    :



(If you are applying on behalf of someone else, send the documents showing that you are authorized to apply (such as a document showing that the person is the parent/guardian of the person concerned, power of attorney, etc.) in the annex of the application. For these documents to be considered valid, they must be issued or approved by the competent authorities.)