Juxly

This HIPAA-compliant form may be used to securely share Protected Health Information (PHI) with Juxly. Data you share will be handled in accordance with existing Business Associate Agreements (BAAs) and comply with the policies of Juxly HITRUST certification.

Juxly will review content submitted with this form within 1 business day.

Submitter

First name

Last name

Company

Title

Email address

Phone number

Practice name (if different than Company)

Salesforce case number for this transmission (optional)

Content

Message

Files

Add file

Please upload a file

Permission to transmit

My company has a fully executed BAA in place with Juxly

Your information will be encrypted.