Easy Pak Return Form

Using MedSafe’s Easy-Pak pharmaceutical waste mail-back kit constitutes acceptance of all terms and conditions, including the acknowledgement of your facility’s status as a Conditionally Exempt Small Quantity Generator. Customer shall pack and seal the Easy-Pak in accordance with the instructions included with the kit and comply with all shipping instructions. Each Easy-Pak may only be used for returning pharmaceutical waste as described on the instructions. No biohazards, medical waste or sharps are permitted in to be returned in the kit.

The customer certifies that this container has been prepared and packed in accordance with the MedSafe Easy-Pak instructions and does not include any non-conforming waste. The customer accepts full responsibility as the waste generator for any potential regulatory violations.

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  • If drug wholesaler information is not included, manufacturer credits for eligible items may not be distributed.

Schedule II Drugs to be shipped for processing:

*If returning Schedule II drugs, MedSafe will mail a completed DEA Form 222 based on the information below to your facility’s mailing address. Do NOT ship Schedule II drugs prior to receiving the Form 222.

EXAMPLE:

# NDC # Name and Strength of Drug # of Containers
Total # of bottles, vials, injections, etc.
Total Quantity Shipped
# of oz., patches, tablets, ml, etc.
1 00409-9094-22 Fentanyl Citrate 50mcg/ml 2 4 ml
2 59011-0440-20 OxyContin 40mg 1 20 CT
3 00781-7240-55 Fentanyl Transdermal 12mcg/h 1 3 Patches

Fill out form below:

# NDC # Name and Strength of Drug # of Containers
Total # of bottles, vials, injections, etc.
Total Quantity Shipped
# of oz., patches, tablets, ml, etc.
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Schedule III, IV, V Drugs to be shipped for processing:

EXAMPLE:

# NDC # Name and Strength of Drug # of Containers
Total # of bottles, vials, injections, etc.
Total Quantity Shipped
# of oz., patches, tablets, ml, etc.
1 0641-6061-01 Midazolam 5mg/mL 1 1ML
2 0641-6044-01 Lorazepam 2mg/mL 7 7ML
3 0409-1273-32 Diazepam INJ 10mg/2mL 34 68ML

Fill out form below:

# NDC # Name and Strength of Drug # of Containers
Total # of bottles, vials, injections, etc.
Total Quantity Shipped
# of oz., patches, tablets, ml, etc.
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