jay configurefit order form

Transcription

JAY CONFIGUREFIT ORDER FORM
Effective May 2010
Account #
Date:
Ship To:
PO#
Buyer:
Address:
Marked For:
ATS/RTS Name:
City / State:
o Assemble to Base
Chair Order #:
Zip Code:
Phone Number
The HCPCS codes provided are based on code verification by the PDAC or our interpretation of the code definitions. Proper use of HCPCS codes does not ensure coverage or payment. For coverage information, verify the appropriate payer's coverage policy.
General Information
Start
STEP 1
Mobility Base Information
STEP 2
Shoulder Width P-A
Chest Width P-B
Hip Width P-C
Width at Knee P-D
Seat to Top of Head P-E
Seat to Top of Shoulder, Left P-FL
Seat to Top of Shoulder, Right P-FR
Seat to Axilla, Left P-GL
Seat to Axilla, Right P-GR
Seat to PSIS P-H
Chest Depth P-K
Back to Anterior of ITs P-L
Posterior Pelvis to Popliteal, Left P-ML
Posterior Pelvis to Popliteal, Right P-MR
Foot Length, Left P-NL
Foot Length, Right P-NR
Seat to Footplate, Left P-OL
Seat to Footplate, Right P-OR
STEP 4 Seating System Fabric/ Embroidery Specifications
Embroidery Information (Must order Back)
Seat Fabric: Contact
Text
Seat Fabric: Non-Contact
"
Back Fabric: Contact
Back Fabric: Non-Contact
Script
oBlock
Style
Ancillary/Secondary: Contact
Thread Color
Ancillary/Secondary: Non-Contact
oStyle A
oStyle R
Stock Monogram
Style Sheet Selection
Mobility Base Manufacturer
Mobility Base Model
Width (in.)
Depth (in.)
Back Cane Height
Armrest Type
Seat Tubing Diameter
Upper Back Cane Tubing Dia.
Lower Back Cane Tubing Dia.
Joy Stick Location
STEP 3
Seating System Dimensional Specifications
o Sunrise Completes*
Seat Width
Back Width
Distance Between Lat Thor
Dist Between Pel Laterals
Usable Seat Depth
Total Seat Depth
Back Height
Seat to top Lat Thor, Left
Seat to top Lat Thor, Right
Dist Between Lats at Knee
Patient Dimensional Information
1-A
7-A
8-F
3-F
1-XX
1-B
7-B
8-GL
8-GR
4-F
*Requires all patient measurements
"
(Style A is default)
n
CS-01-SEAT
Step 1: Select Contour
Custom Configured Seat
Retail Price: Derived by adding all items in Zone 1 (Ea)
Zone 1
BASE REGION
Complete Diagram page
o CS-01-1000
Flat Seat $195
o CS-01-1010
Step 2: Select Base
 CS-01-3000 Standard Base (1/2" Thick)1
 CS-01-3010 Omit Base 2
o CS-01-3040 ABS Base (no T-Nuts)3
N/C
N/C
$30
Wedge Seat
$355
 CS-01-1020 Anti-Thrust Seat
o CS-01-1030 Quick Fit Adj Anti-Thrust St.
 CS-01-3050 Custom Base 4,6
o CS-01-3020 Heavy Duty Base 5(3/4" thick)
 CS-01-3030 PlastiTech Base 3 (1/2" Thick)
Ordering Information and Customer Service: 800-333-4000 Fax: 877-237-4214
$185
$65
$30
HCPCS Code E2609
$355
$545
 CS-01-1040
o CS-01-1050
Contoured Seat
Quick Fit Adj Contoured Seat
1 - Must select for Transit - Weight Limit 250lbs -Transit 200lbs
2 - Must have surface to mount on Mobility Base
3 - Light Duty Use Only - no Transit
4 - No Transit
5 - No Transit - Weight Limit 300lbs
6 - Use note section at the end of the diagram page to specify
www.sunrisemedical.com Specifications are subject to change without notice. Copyright @2010 Sunrise Medical 116024 REV. C
Page 1
$495
$635
BASE REGION
Step 3: Select Foam
 CS-01-2020 Omit Foam
 CS-01-2000 Standard Foam (1.5" HR 70)

Non-Standard Foam (use grid)
 CS-01-2010 1" Med/Soft Sunmate over 1/2" HR 70
 Cust. Foam (Complete & attach custom foam diagram
N/C
$0
page from Zone 1 in product selection guide.
Transfer calculated price to this page.)
0
$75
$
Choose only one box per row (When ordering Qty 2 of any foam below - the result will be a 1" piece of non-laminated foam)
Seat Schematic
Layer 4
Layer 3
Layer 2
Bottom Layer 1
Sunmate $35 / Half Inch
o
o
o
o
Soft
Soft
Soft
Soft
o
o
o
o
Med/Soft
Med/Soft
Med/Soft
Med/Soft
Visco Foam $45/ Half Inch




Med
Med
Med
Med
o
o
o
o




Med
Med
Med
Med




High Resiliancy $15/Half Inch




Pudgee
Pudgee
Pudgee
Pudgee




HR 50
HR 50
HR 50
HR 50
1" = QTY 2
ENTER QTY
Price = Qty x Price per Half Inch
HR 70
or
HR 70 1.5" = QTY 3
2" = QTY 4
HR 70
etc...
HR 70
 Add the price of these options to the price of the Seat
Choose the pricing option for items selected in Steps 4 through 6:
 Required
Pudgee $90/Half Inch
X-Soft
o Soft
X-Soft
o Soft
X-Soft
o Soft
X-Soft
o Soft
Plywood Base Material
o List the price of these items separately
Step 4: Select Additional Modifications (Complete Diagram page where necessary)
Additional Shape/Cover Modifications
Attaching Strips, Hook on Bottom
Attaching Strips Loop, on Bottom
 CS-01-4610
 CS-01-4640
 CS-01-4790
 CS-01-4040
Additional Structural Modifications
o CS-01-4450
 CS-01-4400
o CS-01-4460
 CS-01-4650
$35
$35
$75
$115
Incontinent Film Covering
Undercut Front Seat Edge
Write in Shape/Cover Modifications from Product Selection Guide:
$110
N/C
$110
$110
I Seat
Standard 2" x 3" Back post Notch
Mid-Seat Cutout for X Brace
Seat Rail Foam Overlay
$
$
Write in Structural Modifications from Product Selection Guide:
$
$
BASE REGION
$0
o Adj. Rails (Tracks) for Mounting Hip Supports
$145
o Adj. Rails (Tracks) Running Depth of Seat
1
$145
 Single Slot Adjustment Rails
o Double Slot Adjustment Rails
Step 6: Select Attaching Hardware
Front Seat Hardware (Sunrise selects part number)
 Universal Hardware Transit
o Universal Hardware
o Adj Drop Hook Style
 Fixed Drop Hook Style
 EZ Mount Style
o Snap On Style
o Omit Hardware
Rear Seat Hardware (Sunrise selects part number)
1
 Universal Hardware Transit
o Universal Hardware
 Adj Drop Hook Style
o Fixed Drop Hook Style
 EZ Mount Style
 Snap On Style
 Omit Hardware
3
 Seat Tabs
$300
$275
$85
$85
$145
$140
N/C
Write in from Product Selection Guide
2
n
OTHER
Items selected WILL NOT Be rolled into Back Price
Write in From Product Selection Guide
$
Single Pull Anterior Pelvic Support Unpadded
o 1"
 1.5"
o 2"
 Plastic Side Release
o 1"
 1.5"
o 2"
CS-02-PELVICSPP
Select Buckle Style
3 - Must order a Back (CS-07-BACK) with a Seat/Back Bracket in
Step 7 of CS-07-BACK
$
$45 EACH
HCPCS Code E0978
$55 EACH
HCPCS Code E0978
Select Buckle Size
o Push Button Release
n
2 - Must order Universal Transit Hardware Front of Seat
Retail Price: Each selection below creates 1 Ea. Part # w/ price
CS-02-PELVICSPU
Select Buckle Style
1 - Must order Seat Tabs or Universal Transit Hardware for rear of
seat. If ordering Seat Tabs, must order a Back
(CS-07-BACK) with a Seat/Back Bracket in Step 7 of CS-07-BACK
$
$
n
$300
$275
$85
$85
$145
$140
N/C
$30
$
Zone 2  Required
o Sunrise Selects Length
o Write Length Part No. Below
Dbl slot adj. rails provided - skip Parts B and C
BASE REGION
PART C
 No Adjustment Rails (Tracks) Required
PART B
PART A
Zone 1
Step 5: Select Adjustment Rails (Tracks)
Single Pull Anterior Pelvic Support Padded
Select Pad Size Corresponding to Buckle Size
Select Buckle Size
o
1"
o
1.5"
o
2"
 4.5" Long 1
 5.5" Long
1 - Size available in push button only.
 7.5" Long
 7.5" Long
 9.5" Long
 9.5" Long
 11.5" Long
Page 2
Zone 2 o Required
BASE REGION
n
CS-02-PELVICDPP
Select Buckle Style
n
Select Buckle Style
$60 EACH
 4.5" Long 1
 5.5" Long
 7.5" Long
 7.5" Long
1 - Size available in push button only.
 9.5" Long
4 Point Anterior Pelvic Support Padded
$110 EACH
HCPCS Code E0978
Select Buckle Size
o 1.5"
 4.5" Long
 5.5" Long
 6.5" Long
OTHER
$
n
HCPCS Code E0978
o 1"
o 1.5"
CS-02-PELVIC4PP
n
Dual Pull Anterior Pelvic Support Padded
Select Buckle Size
CS-03-HIP
$
Lateral Pelvic Supports with Any Type Hardware
$
$125 Ea ($125 for Left and $125 for Right)
HCPCS Code E0956
When using separate Pelvic and Adductor supports complete the section below and then complete Zone 4 to add the Adductor Pads
Step 1: Select Pad
Left
Right












 Required
Zone 3
BASE REGION
1
2
Step 2: Select Bracket Style
o Check Box if Mounting to Back
1
Custom Pelvic/Thigh Pad
2
Contoured Pelvic/Thigh Pad
3 H x 4 L Pelvic Pad
Left
Right












Step 3: Select Offset
Left
3
Omit (Upgrade) Brkt (to upgrade to Rem Brkts)
Omit (Upgrade Modu) Brkt (Upgrade to Modular Brkts)4
Fixed Bracket
Fixed HD Bracket
Fixed 15 Degree Bracket
5
Adjustable Profile Bracket






Step 4: Select Profile
Right






Left Right
Sunrise Selects
Flush (not available Adj Profile)
1" Offset
2" Offset
1" Reverse Offset (not avail
with adj profile)
Complete CS-03-1100 on diagram page
3
Skip Steps 3 and 4 and complete CS-03-HIP_REM
If ordering contoured seat, contoured pads should be ordered - complete CS-03-1110 on diagram page
4
Skip Steps 3 and 4 and complete CS-03-MODU
n
5





Lateral Pelvic Support Bracket Modifications section
Retail is derived from the pick(s) below (Ea Left and Ea Right)
Left Right
1  Sunrise Selects
  Standard
  Medium
2  High
  Extra High
n CS-03-MODU
Upgrade Lateral Pelvic Supports to Modular Hardware
Left Right
Left
Right
$145

 Modular Fixed Bracket

 Sunrise Selects
$145

 20 Deg Adj Modular Fixed Brakt

 Flush

 1" Offset

 2" Offset

 1" Reverse Offset
Lateral Pelvic Support Bracket Modifications
HCPCS Code E1028
Flush and 1" offset only, Standard
and Medium Profile only
Used for mounting to Mobility
Base Tracking Systems
HCPCS Code K0108
Left Right










Sunrise Selects
Standard
Medium
High
Extra High
Each Selection = 1 Each part number w/ price (Ea Left and Ea Right)
Left
Adjustable Profile Upgrade
Sunrise Selects
Standard
Medium
High
Extra High
Skip step 3 and select CS-03-3055 Adj Profile Upg from
CS-03-HIP_REM
Upgrade Lateral Pelvic Supports to Removable Hardware
Left Right
Left
Right
$195

 Standard Removable

 Sunrise Selects
$195

 20° Adjustable Removable

 Flush
$215

 Large Target Button Rem 1

 1" Offset
$235

 Rail Mount (Track) Removable 2

 2" Offset

 1" Reverse Offset
Left Right

 CS-03-3055







$25
HCPCS Code K0108
Right


$
CS-03-3025
CS-03-3050
1/4" Bracket Spacer
1/2" Bracket Spacer
$20
$20
$
Lateral Pelvic Support Pad Modifications
Each Selection = 1 Each part number w/ price (Ea Left and Ea Right)
Left
Right
$
$
Left
Right
$
$
Page 3
n
CS-04-ADD
Lateral Adductor Supports with Any Fixed Hardware
HCPCS Code E0956
Select either CS-04-ADD (adductor mounted to seat) OR CS-04-ADD_FM (adductor mounted to mobility base frame)
Step 1: Select Pad
Left
Right
Left Right








3 H x 4 L Adductor Pad
Custom (Complete size below)
Left Size _____H x _______L
Left
Right










Left
1
Omit (Upgrade) Brkt (Select for Rem Brkts)
2
Omit (Upgrade) Brkt (Upgrade for Modular Brkts)
Fixed Bracket
Fixed HD Bracket
Adjustable Profile Bracket
3
Right















Sunrise Selects
Flush
1" Offset
2" Offset
1" Reverse Offset





Sunrise Selects
Standard
Medium
High
X-HP
Right Size _____H x _______L
1 - Skip Steps 3 and 4 and complete CS-04-ADD_REM
o Required
Zone 4
BASE REGION
n
CS-04-ADD_REM
Step 1: Select Style Bracket
Left
Right








2 - Skip Steps 3 and 4 and complete CS-04-ADD_MODU
Upgrade Lat Adductor Supports to Removable
Standard Removable
20 deg Adjustable Rem
1
Large Target Button Rem
Rail Mount (Track) Rem
$195
$195
$215
$235
Left
Right










3 - Skip step 4 and select CS-04-3055 Adj Profile Upgrade from Modifications section
HCPCS Code E1028
Step 4: Select Distal Offset Adapter
Left
Right





Sunrise Selects
Flush
1" Offset
2" Offset
1" Reverse Offset





Left Right


Sunrise Selects
Standard
Medium
High
Extra High


2" Distal
3" Distal
$25
$25
1 - Flush and 1" Offset only, Standard and Medium Profile only - NO Distal Offset adapter available -Skip step 4
n
CS-04-MODU
Left
Right




n
Modular Fixed Bracket
20 Deg Adj Modular Fixed Brkt
CS-04-ADD_FM
Step 1: Select Pad
Left
Right






Upgrade Lat Adductor Supports to Removable
$145
$145
Left
Right










HCPCS Code K0108
Step 4: Select Distal Offset Adapter
Left
Right





Sunrise Selects
Flush
1" Offset
2" Offset
1" Reverse Offset
Frame Mount Lateral Adductor Supports with Fixed Hrdw





{
Left
Right


2" Distal
3" Distal
$25
$25
HCPCS Code E0956
Right


Size ________H x ________L
Size ________H x ________L


Left
3" Round Adductor Pad
4" Round Adductor Pad
Custom
Left Right
Sunrise Selects
Standard
Medium
High
Extra High


Fixed Bracket
Upgrade to S/A Brkt (Complete to CS-04-ADD_SA)
1
n
CS-04-ADD_SA
Left
Right








Sunrise Selects
Long Arm
Short Arm
Custom Arm Length
Upgrade Frame Mount Adductor Supports to Swing
$260
$260
$260
$295
HCPCS Code E1028
Each Selection = 1 Each part number w/ price (ea Left and Ea Right)
HCPCS Code K0108
Custom Arm Length ____________________
Lateral Adductor Support Bracket Modifications
Left Right

 CS-04-3055
Left


$25
Right


$
CS-04-3025
CS-04-3050
1/4" Bracket Spacer
1/2" Bracket Spacer
$20
$20
$
Lateral Adductor Support Pad Modifications
Each Selection = 1 Each part number w/ price (ea Left and Ea Right)
Left
Right
$
$
Left
Right
$
$
Page 4
n
CS-05-ABD
Step 1: Select Pad Style
Required
Zone 5
BASE REGION


n
Medial Thigh Support with Fixed Bracket
Step 2: Select Pad Size





Oval
Wedge
CS-05-ABD_REM
$170 EACH
HCPCS Code E0957
Step 3: Select Bracket
 Fixed
 Upgrade to Flip Down or
Removable (Complete
CS-05-ABD_REM)
X-Small (Oval only)
Small
5-A________________
Medium
5-B________________
Large
5-C_______________
Custom
5-D_________________
5-E_________________
5-F_________________
Medial Thigh Support Removable/Retractable Upgrade
Choose only one item from this section
 Push Button Flip Down Upgrade
 Push Button Removable Slide-out Upgrade
 Narrow Profile Push Button Flip Down Upgrade
 Narrow Profile Push Button Removable Slide-out Upgrade
Retail is derived from the pick made below (Ea)

Pull Away Upgrade

Hide Away Upgrade (L Mount)

Hide Away Upgrade (T Mount)

Adjustable Hide Away Upgrade

Swing Away Upgrade
$245
$275
$245
$275
HCPCS Code E1028
$285
$375
$375
$405
$255
Medial Thigh Support Bracket Modifications
HCPCS Code K0108
$
$
Medial Thigh Support Pad Modifications


CS-05-3140 1/2" Pudgee Foam in Medial Support
CS-05-3220 7/8" Akton Polymer in Medial Support
HCPCS Code K0108
$55
$70
$
Lower Extremity Supports
Each Selection Below Creates 1 Each of Part Number
Zone 6
LOW EXTREMITY REGION
See Product Selection Guide for Sizes
SHOE HOLDER
FOOT AND ANKLE POSITIONER
$
Padded Straps?

CS-06-1010L
ABS Shoe Holder Left E0951/E0952
$80
Yes oNo
SM
oMED
SIZE
LG
oX-LG
 CS-06-1050L
Foot and Ankle Positioning Left
K0108 $80
SM
oMED
LG
oX-LG

CS-06-1010R
ABS Shoe Holder Right E0951/E0952
$80
Yes oNo
SM
oMED
LG
oX-LG
o CS-06-1050R
Foot and Ankle Positioning Right
K0108 $80
SM
oMED
LG
oX-LG

CS-06-1030L Tendon Relief Shoe Hldr Left E0951/E0952
$80
Yes oNo
SM
oMED
LG
oX-LG
 CS-06-1070L
Ankle Positioner Left
K0108 $80
XSM

CS-06-1030R Tendon Relief Shoe Hldr Right E0951/E0952
$80
Yes oNo
SM
oMED
LG
oX-LG
o CS-06-1070R
Ankle Positioner Right
K0108 $80
XSM
□SM
□SM
TENDON RELIEF SHOE HOLDER
SIZE
$
ANKLE POSITIONER
$
$
Page 5
oMED LG oXLG
oMED LG oXLG
n
CS-07-BACK
Custom Configured Back
Retail Price is derived by adding all items in Zone 7 (Ea)
Only certain contour options are available depending on base selection - Use
this column for flat structural base.
HCPCS Code E2617
Only certain contour options are available depending on base selection Use this column for curved structural base
Step 1: Choose Contour by Structural Base Option - FLAT BASE
Step 1: Choose Contour by Structural Base Option - CURVED BASE
OR
 CS-07-1005
 CS-07-1020
 CS-07-1120
Flat Back
Curved By Foam Back
$195
Contoured Back
 CS-07-1010
 CS-07-7120
$635
$495
Contoured Back
 CS-07-7105
Quick Fit Contour Back
Diagram in Product Selection Guide indicate dimensions
using Write in Section of Diagram Page
o Required
Zone 7
TORSO REGION
Quick Fit Contour Back
$530
 CS-07-7130
$615
1
 CS-07-1030
$485
Bi-angular Back
1
 CS-07-1031
$595
Curved by Foam Bi-angular Back
 CS-07-1100
Quick Fit Contour/
$695
1
Bi-angular Back
1
$340
$315
 CS-07-1105
Curved Back
$570
2
Bi-angular Back
2
 CS-07-7100
Quick Fit Contour/Bi-angular Back
2
$795
Select Bi-angular Back Bracket Style below
Select Bi-angular Back Bracket Style below
 Sunrise Selects Bracket (Tooth Style Standard)
 Sunrise Selects Bracket (Tooth Style Standard)
OR
 CS-07-1130
OR
Foam Form Back
$545
Use Product Selection Guide to complete the boxes below
$
$
$
Write in Left Lateral
Write in Right Lateral
Write in FIP Kit
Step 2: Choose Structural Base Option from the same column as above
Select Flat Base
 CS-07-3000
 CS-07-3010
 CS-07-3040
 CS-07-3050
 CS-07-3020
 CS-07-3030
3
4
5
6
7
3
Standard Base (1/2" Thick)
4
Omit Base
5
ABS Base (no T-Nuts)
6
Custom Base
7
Heavy Duty Base (3/4" Thick)
5
PlastiTech Base (1/2" Thick)
OR
N/C
N/C
$30
$195
$60
$30
Must select for Transit - Weight Limit 200lbs Transit/250lbs non-Transit
Must have surface to mount on Mobility Base
Light Duty Use Only - no Transit
No Transit - specify using notes on diagram page
No Transit - Weight Limit 300lbs
Step 2: Choose Structural Base Option from the same column as above
Select Curved Base
 CS-07-3060
 CS-07-3070
9
Curved Back Base
10
Curved PlastiTech Back Base
N/C
$60
9 Can use with Transit - Weight Limit 200lbs Transit/250lbs non-Transit
10 No Transit - Weight Limit 150lbs
Page 6
Step 3: Select Foam
 CS-07-2020
Omit Foam
N/C
 CS-07-2025

Standard Foam (1" HR 70)
$0
 CS-07-2030 1" Med/Soft Sunmate
 Cust. Foam (Complete & attach custom foam diagram
$75
page from Zone 7 in product selection guide.
Transfer calculated price to this page.)
Non-Standard Foam (use grid)
$
0
Choose only one box per row (When ordering Qty 2 of any foam below - the result will be a 1" piece of non-laminated foam)
Back Schematic
Sunmate $35 / Half Inch
Visco Foam $45/ Half Inch
Pudgee $90/Half Inch
High Resiliancy $15/Half Inch
Layer 4
o Soft
o Med/Soft
 Med
o X-Soft
o Soft
 Med
 Pudgee
 HR 50
Layer 3
o Soft
o Med/Soft
 Med
o X-Soft
o Soft
 Med
 Pudgee
 HR 50
Layer 2
o Soft
o Med/Soft
 Med
o X-Soft
o Soft
 Med
 Pudgee
 HR 50
Bottom Layer 1
o Soft
o Med/Soft
 Med
o X-Soft
o Soft
 Med
 Pudgee
 HR 50
1" = QTY 2
ENTER QTY
Price = Qty x Price per Half Inch
 HR 70
or
 HR 70 1.5" = QTY 3
 HR 70 2" = QTY 4
etc...
 HR 70
Plywood Base Material
 Add the price of these options to the price of the Seat
Choose the pricing option for items selected in Steps 4 through 7:
o List the price of these items separately
Step 4: Select Additional Modifications (Complete Diagram page or Find Diagram in Product Selection Guide and Use Write in Section of Diagram Page)
Write in Shape/Cover Modifications from Product Selection Guide:
o CS-07-4400 I Style Back
 CS-07-4410 T Style Back
o CS-07-4640 Two Piece Cushion & Base Back
$55
$130
$110
$110
$110
$145
$
$
$
 No Lumbar Support
1
o CS-07-6040 Internal Lumbar Roll
1
o CS-07-4920 External (Upholstered) Lumbar
2
o Adjustable Lumbar (Skip Part B)
$0
$135
$135
$280
PART B
Step 5: Select Lumbar Support
PART A
Foam Density
Foam Type
o Sunmate
o Visco
 Soft
 X-Soft
 Med/Soft
 Soft
1 - Complete Diagram Page
2 - Cannot be used with Bi-Angular Back - Complete
Diagram in Zone 7 of Diagram Page
(CS-07-6000, CS-07-6010, CS-07-6020)
 Med
 Med
 No Adjustment Rails (Tracks) Required
$0
o Adj. Rails (Tracks) for Mounting Lat Supports
$145
o Adj. Rails (Tracks) Running Depth of Back
$145
 Single Slot Adjustment Rails
PART C
PART A
Step 6: Select Adjustment Rails (Tracks)
PART B
 Required
Additional Structural Modifications
Waterfall Back Modification
Scapular Contour Cutout Back
Back Channel Cutout
$
Zone 7
TORSO REGION
Additional Shape/Cover Modifications
 CS-07-4040
 CS-07-4000
 CS-07-4030
o Double Slot Adjustment Rails
o Sunrise Selects Length
o Write Length Part No. Below
Dbl slot adj. rails provided - skip Parts B and C
Step 7: Select Attaching Hardware
Upper Back Hardware (Sunrise selects part number)







Universal Hardware Transit
Universal Style
Adj Drop Hook Style
Fixed Drop Hook Style
2
EZ Mount Style
2
Snap On Style
Omit Hardware
1
Lower Back Hardware (Sunrise selects part number)
$300
$275
$85
$85
$145
$140
N/C









3
Seat to Back Bracket
3
Adj Depth Seat to Back Bracket
4
Universal Hardware Transit
Universal Style
Adj Drop Hook Style
Fixed Drop Hook Style
2
EZ Mount Style
2
Snap On Style
Omit Hardware
Spacer Options




$165
$230
$300
$275
$85
$85
$145
$140
N/C
Add'l 1/4" Seat depth growth w/ spacers
Add'l 1/2" Seat depth growth w/ spacers
5
Add'l 1" Seat depth growth w/ spacers
5
Add'l 2" Seat depth growth w/ spacers
5
5
1 - Must order either Universal Transit for bottom of back
OR Seat to Back Bracket
2 - Not available with Curved Back Base (CS-07-3060) or
Curved PlastiTech Base (CS-07-3070)
3 - Not appropriate for Reclining wheelchair
4 - Must Order Universal Mount Transit for Top of Back
5 - Must order Seat to Back Bracket from above
$
$
Page 7
$50
$50
$100
$200
n CS-08-LAT
Lateral Thoracic Supports with Any Type Hardware
NOTE: AL and AR indicates need for an additional lateral on that side
Step 1: Select Pad
Step 2: Select Pad Shape


















Left
Right
Ad Left
Ad Right
AL AR







Left











3 H x 3 L Lat Pad
3 H x 5 L Lat Pad
3.5 H x 4 L Lat Pad
4 H x 5 L Lat Pad
4.5 H x 5.5 L Lat Pad
5 H x 6 L Lat Pad
5.5 H x 6 L Lat Pad
1
Upgrd to Contour-Fit
 
Custom
Size _______H x _______L
Size _______H x _______L
Size _______H x _______L
Size _______H x _______L
Right




AL
AR








Step 3: Select Base Material






Right






AL
AR












Omit (Upgrd Rem or S/A)
3
Omit (Upgrade Modular)
Fixed Bracket
Fixed HD Bracket
4
Fixed 15 Degee Bracket
5
Adj Profile Bracket















Required






















CS-08-CF
Step 1: Select Pad Profile
Left Right




Curved
Flat
Upgrade to Contour Fit Lateral Pad
Step 2: Select Pad Contour
Left
Right




D Shaped
Teardrop Shaped
AL AR










Left Right





Sunrise Selects
Flush
1" Offset
2" Offset
1" Reverse Offset
HCPCS Code E1028





AL AR















Sunrise Selects
Standard
Medium
High
Extra High
HCPCS Code E1028
Left Right





Sunrise Selects
Flush
1" Offset
2" Offset
1" Reverse Offset
$145
$145
$200
$200
Sunrise Selects
Standard
Medium
High
6
X-HP





AL AR










Sunrise Selects
Standard
Medium
High
Extra High
HCPCS Code K0108
Left Right AL AR
Modular Fixed Bracket
20 Deg Adj Modular Fixed Bracket
Mod Fixed Brkt w/ Rear Quick Adj.(Not avail. w/ Curved Back)
20° Adj Mod Fixed Brkt with Rear Quick Adj





n CS-08-SA_QR
Upgrade Swing Away Supports to Quick Adjust Hrdw
Rear Quick Adjust not available for Proximal or Profile Adj Proximal Swing Away
Left Right
AL AR
UPGRADE


 
Add Rear Quick Adjust
n





Left Right AL AR
$200
$220
$210
$200
$220
Std 1/4" Closed Cell
1/2" Sunmate
Custom (Use notes on
Adj Profile)
AL AR




Left Right
Sunrise Selects
Flush (not available Adj Profile)
1" Offset
2" Offset
1" Reverse Offset (not avail
n CS-08-MODU
Upgrade Lateral Thoracic Supports to Modular Hrdw
NOTE: AL and AR indicates need for 2nd lateral on that side
Left Right



$195
$195
Swing Away (Not avail. w/ Curved back - use Adj. Angle)
Adj Angle Swing Away
20° Adj. Swing Away (Not avail. w/ Curved back - use Adj. Angle)
Proximal Swing Away (only avail with Std. and Med. Profile)
Adj Profile Proximal S/A - Skip Step 2



AL AR





AL AR
Diagram page)
Left Right AL AR
Standard Removable
20 deg Adjustable Rem



5 - Skip Step 7 and select CS-08-3055 Adj Profile Upgrade from Mods section
6 - Only Available With Flush
4 - Only available as a 1" Offset and 2" Offset
AL AR
 
 






3 - Skip Steps 6 and 7 and complete CS-08-MODU
n CS-08-LAT_SA
Upgrade Lateral Thoracic Support to Swing Away Hrdw
NOTE: AL and AR indicates need for 2nd lateral on that side
Left Right
Zone 8
TORSO REGION





Left Right AL AR
2
n CS-08-LAT_REM
Lateral Thoracic Supports with Any Type Hardware
NOTE: AL and AR indicates need for 2nd lateral on that side.


Left Right
Wood (1/2" Thick base)
Aluminum (3/16" Thick Base)
Plastic (1/4" Thick Base)
Diagram page)
1 - Skip steps 2,3 and 4, Complete 5,6,and 7 and specify pad in CS-08-CF
2 - Skip Steps 6 & 7; complete either CS-08-LAT_REM or CS-08-LAT_SA
Left Right




Diagram page)
Left
Step 4: Select Foam
Left Right AL AR
Curved D (wood mat. n/a)
Flat D
Flat Tapered
HCPCS Code E0956
Left Right





Sunrise Selects
Flush
1" Offset
2" Offset
1" Reverse Offset





AL AR










$50 EACH ($50 Left and $50 Right)
Sunrise Selects
Standard
Medium
High
Extra High
HCPCS Code K0108
$60 EACH ($60 Left and $60 Right)
Step 3: Select Pad Size
Left
Right










Height
Anterior Depth 8-C
5
5
Small
5
7
Med
6
9
Large
7
11
X-Large
Custom - Complete Diagram Page
Medial Depth 8-A
2.5
3
3
3.5
Page 8
Back
Left Right
$125 EACH ($125 for Left and $125 for Right)
Zone 8
TORSO REGION
□Required
Lateral Thoracic Support Bracket Modifications








CS-08-3055
CS-08-1170
CS-08-3025
CS-08-3050
Add Lever Style Summer Winter (Only avail. on Fixed, HD Fixed and Prox. SA Lats.)
1/4" Bracket Spacer
1/2" Bracket Spacer
$25
$55
$20
$20
Lateral Thoracic Support Pad Modifications
Zone 9 oRequired
$
$
$
Right
$

Write in from Product Selection Guide:
CS-08-1430 1/2" Pudgee in Thoracic Support
$40
$
$
$
$
Left
Right
Left
Right
n CS-09-ATS1
Anterior Thoracic Support
Y Style Straps, Back Pack Shoulder Straps and Chest Straps are located in Zone 11
Step 1: Select Style
Step 2: Select Construction
 Classic ComforFit

Structured
 Contour ComforFit

Dynamic
TORSO REGION
Left
Right
Left
Left Right

$160 EACH
Step 3:



n CS-09-ATS2
Center or Zipper Open Style Anterior Thoracic Support
Step 2: Select Size
 Center Opening ComfoFit

Early Intervention
 Zipper Open ComforFit

Extra Small (Not avail. Zipper Open)

Small



$165 EACH
Medium
Large
Extra Large
HCPCS Code E0960
 Medium
 Large
 Extra Large
$195 EACH
n CS-09-ATSTS
Anterior Trunk Strap Support
Step 2: Select Size
 Anterior Trunk Strap

Extra Small
 Anterior Trunk Strap Between Lateral Pads

Small

Medium
$150 EACH
HCPCS Code E0960
Step 3: Select Size
 Small
 Medium
 Large
HCPCS Code E0960
 Large
 Extra Large
OTHER

HCPCS Code E0960
Select Size
Early Intervention (Not avail. In Structured)
Extra Small
Small
n CS-09-ATSBF
Butterfly Style Anterior Thoracic Support
Step 1: Select Function
Step 2: Select Type
 Stretch Style

Butterfly Vest Velcro
 Non-Stretch Style

Butterfly Vest Side Release all 4 corners

Butterfly Vest Side Release Pull Down

Butterfly Vest Side Release Pull Up
n
HCPCS Code K0108
Write in from Product Selection Guide:
Left Right
CS-09-1385 Strap Guides
$45
TORSO
REGION
Zone 10
$
$
n
CS-10-PRO
Protractor Supports
Step 1: Select Pad
Left Right








3W
3W
4W
4W
x 3 T Protractor Pad
HCPCS Code K0108
$105
$105
$105
$105
Left
Right


Custom
Left
Size _______W x _______T
Right Size _______W x _______T
$125
Left
Right




Angle Adjustable Bracket
Fixed Angle Bracket
Page 9
$135
$50
Zone 12
UPPER EXTREMITY REGION
oRequired
TORSO
REGION
Zone 11
oRequired
n
CS-11-RET
Retractor Supports
Step 2: Select Size
 Padded Shoulder Straps w/ Cam Buckle
$85

9" Pad
 Padded Shoulder Straps w/ Side Rls
$85

12" Pad
Step 1: Select Style and Size (from the same row)
OR

Structured Back Pack Style Shld Straps
$155

12"
 18"

Dynamic Back Pack Style Shld Straps
$155

12"
 18"
$105

Y Style Structured Straps
$155

EI
 Small
 Med
 Lg
 Sheepskin Shoulder Straps w/ Side Rls
$105

Y Style Dynamic Straps
$155

EI
 Small
 Med
 Lg
n
CS-12-UES
Arm Troughs with Hardware
$130 EACH
HCPCS Code E2209
For custom size, make selection from Product Selection Guide and write into the "Other" category below
Left Right



n



Small
Medium
Large
OTHER
CS-13-TRAY
$
$
$
Upper Extremity Support Wheelchair Tray
Basic velcro straps included with every tray - Omit
Straps if ordering hardware upgrade below







n






n
Wood Tray
Wood Tray with Edge Border
Polycarbonate Tray
Polycarbonate Tray with Edge Border
1/4" Polycarbonate Tray
1/4" Polycarbonate Tray w/Edge Border
Omit Strap
CS-13-TRAY_MNT
$
Step 1: Select Tray Style
Zone 13 Required
HCPCS Code K0108
 Sheepskin Shoulder Straps w/ Cam Buckle
n
UPPER EXTREMITY REGION
Retail is derived from the pick(s) below (Each)
Step 2: Select Size
 X-Small
$195
$225
$215
$235
$215
$225
N/C




Retail is derived from the pick below
 Custom Size
Small
Medium
Large
X-Large
Tray Specifications
13-A
13-B
13-C
13-D
Upgrade Tray Mounting Hardware
Toggle Hardware (Tray slotted when using this hdwr)
Slide Tube
Wood Runners (Includes Buckle Style Tray Strap )
S Style Runners (Includes Buckle Style Tray Strap )
Slotted Channels Runners (Includes Buckle Style Tray Strap )
Adjustable Lever
Add $75
HCPCS Code E0950
$110
$295
$75
$70
$75
$195
OTHER
Retail is derived from the pick below





HCPCS Code K0108
$195
$95
$70
$315
$35
Top Drop Hardware
Angle-Cam Hardware (Tray slotted when using this hdwr)
Tube Arm Hardware
Cam and Tube Hrdw
Tray Strap with Side Release Buckle
$
$
$
$
Page 10
Head Support with Fixed Hardware
Retail is derived from the pick(s) below (EACH)
HCPCS Code E0955
n CS-14-HEAD
Select CS-14-HEAD (Whitmyer Mount) OR CS-14-HEAD-OS (Legacy Mount). All pads in this section are designed to mate with Whitmyer brackets found in CS-14-REM. Choose only one.
Step 1: Select Support Style then Select Size Along Same Row










Step 2: Select Fabric
o 6" Pad - $180
o 8" Pad - $180
o 10" Pad - $185
 14" Pad - $185
o 19" Pad - $260
 Small - $165
 Med - $165
 Large - $185
o 14" Pad - $415
o 19" Pad - $425
 12" Pad - $185
o Infant Pad - $140
 Small - $150
o Med - $165
o Large - $175
2
2
5
o Peds 2 - $110
 Infant - $65
 Adult - $110
 T Bar - $70
o Narrow - $285
 Standard - $285
 $115
 3.5" w x 4" t
o 4" w x 4" t
 5" w x 5" t
o 6" w x 6" t
 6.5" w x 6" t
o Wid: ______ Ht:______
o $155
Specify Width____________ Specify Height_______________
 $190
Specify Width____________ Specify Height_______________
1
Plush Pad
C Plush
Dual Plush
Narrow Plush
Contoured Cradle
2
Occipital Pad
Adj -A -Plush
3,4
Flat Head Spt Panel
4
Cust Flat HR Extension
4
Cust Curved Head Spt Ext
n
CS-14-REM
Upgrade to Removable Hardware
o Required
Zone 14
HEAD SUPPORT REGION
n
CS-14-MULTI




AXYS
ONYX
LINX
PRO
$
$
$
$


290
175
290
330
Standard
Swing Away
Upgrade to Multi-Pad System
 Short - $110
 Small - $145
 Infant
o Size 3
o Long - $110
o Large - $150
 Size 1
CS-14-AACC
Anterior Head Support Accessories
Select Style then Select Size Along Same Row
$330
 Pediatric

DFS Squared
$205
 Pediatric

Dynamic Forehead Strap
$415
 Pediatric (red)

Strap Cap
$315
 Pediatric

Hedz-Up
CS-14-LACC
Lateral Head Support Accessories
Step 1: Select Pad Style then Select Size Along Same Row
$230
 Lateral Facial Left
oSpot
 Standard
$230
 Lateral Facial Right
oSpot
 Standard
$425
 Bilateral Facial
oSpot
 Standard
CS-14-3P
HCPCS Code E1028
N/C
$55
HCPCS Code K0108
 Lycra
 Reverse Dartex
o Size 4
 Size 2
Non Flared Pad Style - $220
Adult
Adult
Pediatric (blue)
Adult
o Long
o Long
o Long
HCPCS Code K0108
 Adult
n
n
Standard Non Adjustable, NonRem Bracket
Flared Pad Style - $220





Step 2: Detach Style
$335
$335
$335
Step 1: Select Pad Style then Select Size Along Same Row
 T Bar Pad (Must have Ordered Occipital Pad T Bar Style in CS-14-HEAD)
 Single Sub Occipital
 Dual Sub Occipital
n
 Omit (Upgrade) Brkt to Adj and
Removable (go to section
CS-14-REM)
 Cobra Xtra Early Intervention
 Cobra Xtra Pediatric
 Cobra Xtra Adult
Lycra
Reverse Dartex
4 - Skip Step 2, fabric for these pads will be matched to backrest
colors and fabrics, Cannot add CS-14-AACC or CS-14-LACC.
5 - Must order T Bar Pads from CS-14-MULTI Select Short or Long
3 - Center Portion of 3 panel Head Support complete CS-14-3P
below.
1 - Plush Pad can be used as Occipital Pad allowing Multi-Pad System (CS-14-MULTI)
2 - Order this pad to create multi-pad sytem with sub occipital complete CS-14-MULTI


 Oval
 Oval
 Oval
HCPCS Code K0108
 Lycra
o Large- C  Medium-C
o Small-C  Switch
 Reverse Dartex
3 Panel Head Support Accessories
$260 EACH
HCPCS Code K0108
Fabric for these Pads will be matched to Backrest colors and fabrics
Step 1: Select Pad Size (Check Step 2 footnotes before selecting Pad sizes)
Left Right










3.5" W x 4" T
4" W x 4" T
5" W x 5" T
6" W x 6" T
6.5" W x 6" T

Custom: Write in Custom Pad Size from Product Selection Guide:
Width:___________________ x Tall:________________________
$
Right Width:___________________ x Tall:________________________
$
Left
1 - Center Panel must be no wider than 4"
2 - Center Panel must be between 4" and 5.5" wide
Step 2: Select Hardware
 Sunrise Selects
 One Piece Pad Mount Pediatric1
 One Piece Pad Mount Std 2
 One Piece Pad Mount Wide 3



Space Saver Brackets (Qty2)
4
Spacer Saver Brackets (Qty 4) 5
Taper Joint Brackets (Qty 2)
3 - Center Panel must be 5.5" to 6.5" wide (max)
4 - Recommended for Pads up to 6" tall
Page 11
5 - Pads must be at least 6" tall
n
CS-14-HEAD-OS
Head Support with Fixed Hardware
HCPCS Code E0955
Select either CS-14-HEAD (Whitmyer Mount) OR CS-14-HEAD-OS (Legacy Mount). Pads in this section are designed to mate with brackets in CS-14-REM-OS.
Fabric for these pads will be matched to backrest colors and fabrics
Step 1: Select Support Style then Select Size Along Same Row
 Flat Headrest Extension
$175 Specify Width____________
Specify Height_______________
 Curved Headrest Extension
$200 Specify Width____________
Specify Height_______________
 Flat Head Support Panel
(Center Portion of 3 panel Head
$205  3.5" w x 4" t
o 4" w x 4" t
 5" w x 5" t
o 6" w x 6" t
Support complete CS-14-3P-OS
below)
 Required
Zone 14
HEAD SUPPORT REGION
n








CS-14-REM-OS
Upgrade to Removable Hardware
Lift Away Pediatric (Skip Steps 2,3,4)
Lift Away Adult (Skip Steps 2,3,4)
Adjustable Posterior Head Support (Complete Step 3 Only)
U Bracket Depth Adjustable (Complete Steps 2,3,4)
Hinged U Bracket Depth Adj (Only complete Steps 3 & 4)
L Bracket Depth Adjustable (Complete Step 3 Only)
Hinged L Bracket Depth Adj (Only complete Steps 3 & 4)
Offset Adjustable Posterior Head Supt (Complete Step 3 Only)
 Omit (Upgrade) Brkt to Adj and
Removable (go to section
CS-14-REM-OS)
 6.5" w x 6" t
$110
$110
$120
$240
$305
$240
$305
$120
Step 1: Select Pad Size (Check Step 2 footnotes before selecting Pad sizes)
n
3.5" w x 4" t
4" w x 4" t
5" w x 5" t
6" w x 6" t
6.5" w x 6" t

Width:___________________ x Tall:________________________
$
$
OTHER
Step 4: Select U-Bracket Size
 Sunrise Selects
 Standard
 Long
 Short
HCPCS Code K0108
Step 2: Select Hardware
 Sunrise Selects
 One Piece Pad Mount Pediatric1
 One Piece Pad Mount Standard 2
 One Piece Pad Mount Wide 3
Custom: Write in Custom Pad Size from Product Selection Guide:
Right Width:___________________ x Tall:________________________
Left
HCPCS Code E1028
Step 3: Select Mounting Block
 Sunrise Selects
 Standard
 Large
$260 EACH
Left Right





Standard Non Adjustable, NonRem Bracket
Step 2: Select Upright Length
 Sunrise Selects
 Standard
 Pediatric
n CS-14-3P-OS
3 Panel Head Support Acc. Legacy Mount
Fabric for these Pads will be matched to Backrest colors and fabrics






o Wid: ______ Ht:______



Space Saver Brackets (Qty2)
1 - Center Panel must be no wider than 4"
3 - Center Panel must be 5.5" to 6.5" wide (max)
2 - Center Panel must be between 4" and 5.5" wide
4 - Recommended for Pads up to 6" tall
$
$
$
$
4
Spacer Saver Brackets (Qty 4) 5
Taper Joint Brackets (Qty 2)
Page 12
5 - Pads must be at least 6" tall
Jay ConfigureFit Diagrams
Marked For:
ATS/RTS Name:
CS-01-1000
CS-01-1000
CS-01-1010
Provide Dimensions
CS-01-1010
CS-01-1020
CS-01-1020
Provide Dimensions
Provide Dimensions
1-A
1-A
1-A
1-B
1-B
1-C
1-D
1-B
1-D
1-E
1-I
1-I
All Dimensions are Foam ONLY - do not include base thickness in measurements
CS-01-1030
CS-01-1030
CS-01-1040
Provide Dimensions
Select Custom Contour OR Available Standard Contour
CS-01-1040
Provide Dimensions
1-A
1-B
1-D
1-I
Zone 1
BASE REGION
1-E
Please complete 1-A, 1-B, 1-E and 1-F for Mild, Medium and Aggressive Contours
CS-01-1050
CS-01-1050
Provide Dimensions
CS-01-4000
CS-01-4000
1-A
1-B
1-D
1-E
1-F
1-G
1-GG
1-HL
1-HR
1-IL
1-IR
Page 13
Provide Dimensions
1-A
1-B
1-C
1-N
1-O
CS-01-4450
CS-01-4010
CS-01-4095
CS-01-4010
Provide Dimensions
CS-01-4450
CS-01-4095
Provide Dimensions
Provide Dimensions
1-A
1-A
1-A
1-B
1-B
1-C
1-D
1-JL
1-E
1-JR
1-I
1-KL
Zone 1
1-B
1-C
1-N
BASE REGION
1-O
1-KR
1-ML
1-MR
CS-03-1110
CS-03-1110
LEFT
Provide Dimensions
Check Box to Fit to Contour
Zone 3
CS-03-1100
CS-03-1110
RIGHT
Provide Dimensions
CS-03-1100
CS-03-1100
LEFT
Provide Dimensions
RIGHT
Provide Dimensions
Check Box to Fit to Contour
3-AL
3-AR
3-AL
3-AR
3-BL
3-BR
3-BL
3-BR
3-LL
3-LR
3-ML
3-MR
CS-06-2700R
CS-06-2700R
CS-06-2700L
CS-06-2700L
CS-06-2740
Provide Dimensions
CS-06-2740
Provide Dimensions
6-A
6-A
6-B
6-B
6-C
6-C
6-A
Zone 6
LOWER EXTREMITY REGION
Provide Dimensions
6-B
6-C
6-C
Page 14
CS-07-1005
CS-07-1020
CS-07-1005
Provide Dimensions
CS-07-1030 OR
CS-07-7130
CS-07-1020
CS-07-1030 OR CS-07-7130
Provide Dimensions
Provide Dimensions
7-A
7-A
7-A
7-B
7-B
7-B
7-C
7-C
7-C
7-Z
7-S
7-ZZ
7-T
CS-07-1120 OR
CS-07-7120
CS-07-4400
CS-07-1120 OR Cs-07-7120
CS-07-4410
CS-07-4400
CS-07-4410
Provide Dimensions
Zone 7
Provide Dimensions
CS-07-4920
CS-07-6040
CS-07-4020
CS-07-6040
Provide Dimensions
CS-07-6000
CS-07-6000 OR
CS-07-6010 OR
CS-07-6020
Provide Dimensions
7-C
7-C
7-PP
7-PP
7-QQ
7-QQ
Apex
1
Apex
Selection below determines part number
Select Adj Rail Height
Sunrise Selects Rail Length
3" Rail
(CS-07-6010)
5.5" Rail (CS-07-6000)
7.5" Rail (CS-07-6020)
1
Apex
1
1
Apex Height Measured from Bottom of Back to Center of Pad
CS-08-2445
CS-08-2515
CS-08-2445
CS-08-2445
LEFT
RIGHT
LEFT
RIGHT
Provide Dimensions
Provide Dimensions
Provide Dimensions
Provide Dimensions
8-A
Zone 8
TORSO REGION
Provide Dimensions
Medial Depth
8-A
Medial Depth
CS-08-2515
8-A
CS-08-2515
Medial Depth
8-A
8-B
8-B
8-B
8-B
8-C
8-C
8-C
8-C
Page 15
Medial Depth
Transfer both the part number of the item and the dimension indicator and then indicate the dimension desired
Special Notes
Use Product Selection Guide to find any
Diagrams not on this form
Write In Dimensions
Part Number
Dimension Indicator
Part Number
Dimension
Dimension Indicator
Part Number
Dimension
Dimension Indicator
NOTES:
Page 16
Dimension

jay configurefit order form

Transcription

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