Document Number:
ACSP-0018
Policy Owner:
Student Affairs
Revision #:
v1.0
Status:
Approved

General Description

Policy Summary:

This Notice of Privacy Practices ("Policy") describes how your Protected Health Information (PHI) may be used, disclosed, protected, and how you can access your PHI. Trinity University ("University") is committed to protecting your privacy and complying with applicable federal and state laws, including the Family Educational Rights and Privacy Act (FERPA), as appropriate.

Purpose:

Our practice is dedicated to maintaining the privacy of your PHI. In conducting our business, we will create records regarding you and the treatment we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. By Federal and State law, we must follow the terms of the notice of privacy practices that we have in effect at this time.
 
These laws are complicated, so it is important that we provide you with the following information:
 
  •       How your PHI may be used or disclosed
  •       Your individual rights
  •       The responsibilities of Counseling Services
  •       Our commitment to the confidentiality and integrity of your records

Scope:

This policy applies to all individuals receiving services through Trinity University Counseling Services, and to all employees, contract clinicians, trainees, and administrative personnel authorized to handle confidential health information.


Treatment
Your mental health information may be disclosed to other health professionals at Counseling Services for the purpose of evaluating your mental health and providing treatment. For example, post-session documentation will be available in your medical record to all Counseling Services providers who may provide treatment. We may use and disclose PHI to Trinity University Health Services providers when mental health symptoms may be related to an underlying health condition. A Counseling Services provider will share PHI with an off-campus provider (e.g., psychiatrist) only with your permission.
 
Counseling Services Operations
Your mental health information may be used as necessary to support the day-to-day activities and management of Trinity University Counseling Services. For example, de-identified information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.
 
Compliance with the Law
Your mental health information may be disclosed without your permission when required by federal, state, or local law. This includes disclosures for government audits, inspections, and mandated reporting. Examples of such disclosures include:
  • Compliance with court orders
  • Mandatory reporting of current child or elderly abuse or neglect, or other legally mandated reporting incidents.
  • Health oversight activities conducted by authorized government agencies

When feasible, you will be notified in advance of such disclosures, unless prohibited by law.
 
Serious Threats to Health or Safety
We may disclose your PHI to medical, mental health, or law enforcement personnel if the provider determines there is a probability you will engage in imminent life-threatening injury to yourself or others, or if there is a probability of immediate mental or emotional injury to you. If it is determined that you will be transported to a psychiatric treatment facility—whether voluntarily or involuntarily—for evaluation and potential inpatient care, the University requires your counselor to notify the Post-Hospitalization Support Team. This team includes:
 
  1. The Dean of Students, who coordinates post-hospitalization support services, and
  2. The Associate Provost for Academic Affairs, who informs faculty of your absence (without disclosing the reason) and arranges appropriate academic support.

Responsible Department:

  • Student Affairs

Policy Content

  1.  Counseling Services staff may contact clients by phone or email to communicate appointment changes or send a reminder.
  2.  Telephone messages will contain limited protected health information.
  3. Email communication is not a confidential form of communication and will contain limited protected health information.
  4.  Your email address will not be used for external marketing purposes without your permission. You may receive a group emailing from Counseling Services; however,  the other recipients' email addresses will be hidden.
  5. To protect PHI, Counseling Services staff will use trinity.edu addresses. Email within the trinity.edu domain is encrypted. If a student provides us with an alternative email address or emails us from an alternative email address, all email communication from us will be encrypted using an encryption program. 
     
 
  1. Counseling Services staff may route email messages to other members of the staff for information purposes or for expediting a response.
  2. Designated staff may receive and read emails you send to Counseling Services.
  3. Every attempt will be made to respond to your email message within two business days (Monday-Friday, non-holidays). If you do not receive a response from Counseling Services within two business days, please contact us by phone at (210) 999-7411.
  4. Copies of emails sent and received from and to you could be incorporated into your medical record. You are advised to retain all electronic correspondence for your own files.
  5. All team members, including licensed clinicians, trainees, and administrative staff:
  • Are trained on FERPA regulations
  • Adhere to the relevant ethical codes of their professions as well as the confidentiality regulations stipulated in the Texas Health and Safety Code.  
  • Are responsible for securing electronic records.
  • Must promptly report to you any potential data breaches or concerns.
     
  1. Email messages should not be used for emergencies or time-sensitive situations. In the event of a mental health emergency on campus you should immediately call TUPD at (210) 999-7000. For off-campus emergencies call 911. For emergent or time-sensitive situations during business hours, contact Counseling Services by phone at 210-999-7411 or visit the office in person. For after-hours emergencies or time-sensitive situations, call the Counseling Careline at (855) 850-4301.
  2.  Email messages should be used for re/scheduling purposes only. Please save complex or sensitive topics for counseling appointments.
  3. Phone messages may be left on your cell phone during class or other times when you may not wish to be interrupted. You should turn your phone off or silence the ringer during these times.
As a client, you are expected to:
  •       Provide accurate and complete information regarding your health.
  •       Communicate clearly if you have concerns about privacy or safety.
  •       Understand the limitations of confidentiality, including mandatory reporting.
Other uses & disclosures require your authorization. Disclosures of your health information or its use for any purpose other than those listed above require your specific written authorization. If you change your mind after authorizing a use or disclosure of your information, you must submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision.
 
 
You have certain rights under the state and federal privacy standards. These include:
  1. The right to request restrictions on the use and disclosure of your protected health information.
  2.  The right to receive confidential communications concerning your medical condition and treatment.
  3. The right to inspect and receive a copy of your protected health information.
  4. The right to amend or submit corrections to your protected health information.
  5. The right to receive an accounting of how and to whom your protected health information has been disclosed.
  6.  The right to tell us to share information with others involved in your care.
  7. The right to receive a printed copy of this notice upon request.
  1.  We are required by law to maintain the privacy and security of your PHI.
  2.  We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
  3. We must follow the duties and privacy practices described in this notice and give you a copy of it if requested.
  4. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
Right to Revise Privacy Practices. As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. The revised policies and practices will be applied to all protected health information that we maintain.
 
Requests to Inspect Protected Health Information. Your have the right to inspect and/or obtain a copy of your counseling record. Ideally, you would inspect your record in collaboration with your counselor (or the director or associate director if the counselor is not available) who can explain terms or abbreviations, answer your questions, etc.
 
Complaints. If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to:

TRINITY UNIVERSITY COUNSELING SERVICES
Attn: Privacy Officer
ONE TRINITY PLACE #85
SAN ANTONIO, TEXAS 78212-7200

If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of your concern to the same address. You will not be penalized or otherwise retaliated against for filing a complaint. Contact Person: Director of Counseling Services, 210-999-7411.
 

Terms & Definitions

Terms and Definitions:

Term:

Definition:
Protected Health Information -          All "individually identifiable health information" held or transmitted, in any form or media, whether electronic, paper, or oral. "Individually identifiable health information" is information, including demographic data, that relates to:
  • the individual's past, present or future physical or mental health or condition,
  •   the provision of health care to the individual, or
  •  the past, present, or future payment for the provision of health care to the individual,
-          and that identifies the individual or for which there is a reasonable basis to believe it can be used to identify the individual.  Individually identifiable health information includes many common identifiers (e.g., name, address, birth date, Student ID Number).
-          Protected Health Information is maintained separately from the Education Record.
 
Disclosure of Protected Health Information   The act of transmitting Protected Health Information to an individual or organization outside of Counseling Services.
 

Revision Management

Revision History Log:

Revision #:

Date:

Recorded By:
v1.0 7/24/2025 8:05 AM Pamela Mota

 

Vice President Approval:

Name:

Title:
Andrew Wells Vice President for Student Affairs