DisposeRx Form

CareSource offers free DisposeRx^® packets for our members. This will help you dispose of expired drugs or medications you no longer use. Please complete this form to receive your free packet in the mail. Please allow 10-15 business days for your free DisposeRx packet to arrive.

First Name:

Last Name:

Member ID:

This number is found on the front of your Member ID Card.

Address:

Address Line 2

City:

State:

Zip:

Phone:

Email:

How many different medications do you plan to dispose:

How many medications that you plan to dispose of are a pain medication: