Liberty X - Cloudfront.net
Transcription
Liberty X - Cloudfront.net
LIBERTY® X ORDER FORM Company Name/ACCT #: HCPCS CODING: E2622 ADJUSTABLE SKIN PROTECTION P.O. Number: Liberty® X shown with GlideWear® Requested By: Liberty® X Liner and Foam Base Phone: Fax: Email: Ship To: For best results, do not fill out in your browser. Interactive form should be completed using Adobe Reader after saving to your local drive. Then email or print and fax to Customer Service at customerservice@comfortcompany.com or 1.406.522.8563. SIZE & STYLE Please select size in the appropriate fabric chart below. COMFORT-TEK™ SELECTED FOR INCONTINENCE PROTECTION & AN EASILY CLEANED SURFACE. STRETCH-AIR™ $462.19 $462.19 DEPTH LBX-F-1820 LBX-F-2020 LBX-F-1818 LBX-F-2018 19” LBX-F-1618 17” 16” LBX-F-1717 LBX-F-1616 16” SELECTED FOR AIR TRANSMISSION & HEAT DISSIPATION. COMFORT-TEK™ 20” 18” STRETCH-AIR™ OR 20” DEPTH 1 17” 18” 19” LBX-S-2020 LBX-S-1818 LBX-S-2018 19” 18” LBX-S-1618 17” 16” LBX-F-1816 LBX-S-1820 20” LBX-S-1717 LBX-S-1616 16” LBX-S-1816 17” WIDTH 18” 19” 20” WIDTH LIBERTY® X with GLIDEWEAR® is designed to promote healing as well as reduce the risk of skin breakdown. A GlideWear® Shear Reduction Panel is incorporated into the cover under the most at-risk areas to allow for micro-movements without the deformation of tissue. U.S. GLIDEWEAR® Patent No. 8,646,459 COMFORT-TEK™ with GLIDEWEAR® STRETCH-AIR™ with GLIDEWEAR® $499.50 $499.50 LBX-FQ-1820 LBX-FQ-2020 LBX-FQ-1818 LBX-FQ-2018 19” 18” LBX-FQ-1618 17” 16” LBX-FQ-1717 LBX-FQ-1616 16” 18” 19” 20” LBX-SQ-1820 LBX-SQ-2020 LBX-SQ-1818 LBX-SQ-2018 19” 18” LBX-SQ-1618 17” 16” LBX-FQ-1816 17” 20” DEPTH DEPTH 20” LBX-SQ-1717 LBX-SQ-1616 16” LBX-SQ-1816 17” WIDTH 18” 19” 20” WIDTH QUESTIONS? PLEASE CONTACT CUSTOMER SERVICE FOR ASSISTANCE. | 800.564.9248 Liberty® X is not recommended for use in altitudes above 3,000 ft. LIBERTY® X ORDER FORM Patient Reference: PAGE 1 of 3 LIBERTY-X-ORDER REV0316 Patient Reference: 2 2.1 *All accessories are cosmetic changes to the cushion except for options in gray, which are add on items. LIBERTY® X ACCESSORIES COLOR - COMES STANDARD W/ REFLECTIVE BLUE PIPING MSRP $25.00 Accent colors can be applied to the cushion via colored piping. If no colors are selected, our standard reflective blue piping is used. KWIK STRAP® 2.2 MSRP $15.00 2.3 Kwik Strap® provides extra security. Kwik Strap® is connected to the bottom of the cushion via hook & loop attachment and wraps around vertical canes to secure the cushion to wheelchair during transfers. INCONTINENCE LINER MSRP One = $58.00 - Two = $116.00 Liner provides extra incontinence protection for the cushion. Rear View COLOR LOCATION Red (RED) Silver Reflective (SILVER) Purple (PURPLE) Green (GREEN) Pink (PINK) Remove (REMOVE) COVER 2.4 EXTRA MSRP One = $60.00 - Two = $120.00 One Extra Incontinence Liner (INCON-LINER) Kwik Strap® Two Extra Incontinence Liners (INCON-LINER) (KWIK-STRAP) REMOVABLE SOLID SEAT 2.5 PAN & HARDWARE KIT HCPCS Code: E2231 MSRP $375.00 The solid seat pan kit includes a slotted aluminum pan and attaching hardware to accommodate 7/8” or 1” tubing. The kit also comes with two different cross bars to accommodate various wheelchair frame types. This will fit both folding and non-folding seat rails. Lateral trunk supports can be easily attached. 2.6 RIGID INSERT HCPCS Code: E0992 MSRP $63.00 3/16” Plastic rigidizing board. One Extra Stretch Air Outer Cover (X-STRETCH-AIR-CV) Two Extra Stretch Air Outer Cover (2X-STRETCH-AIR-CV) One Extra Comfort Tek Outer Cover (X-COMFORT-TEK-CV) Solid Seat Pan & Hardware Kit Two Extra Comfort Tek Outer Cover (RSSP-N-HARD) (2X-COMFORT-TEK-CV) (RGD-INSERT-UNGLUED) VICAIR® PELVIC STABILIZER MSRP $114.00 (fits) 16W x 16D -OR- 16W x 18D (PS-1618) (fits) 18W x 16D -OR- 18W x 18D (PS-1818) LIBERTY® X ORDER FORM LIBERTY-X-ORDER REV0316 2.7 Rigid Insert Not Glued Patient Reference: PAGE 2 of 3 3 3.1 LATERAL THIGH SUPPORTS & HARDWARE RIGID RIGID CONTOURED MSRP $50.00/ea *Length (L) refers to the actual size dimension of the support from bottom to top edge. Select a left and/or right lateral pad using any combination of style, size and fabric. Contact Customer Service for custom sizes that are not listed below. 1.800.564.9248. LATERAL THIGH SUPPORT PADS HCPCS Code: E0956 (OPTIONAL) INSTRUCTIONS: for Anti-Thrust Cushion MSRP $50.00/ea NOTE: T-Nut spacing along hip guide is 1” on center running the entire length of the pad. L L D STRETCH-AIR STRETCH-AIR FABRIC Extra L SIZE Left FABRIC Right Extra R Extra L Left SIZE Right Extra R (HG1RS3H4D) 3” L x 4” D (HG1RS3H4D) (HG1RS3H4D-AL) 3” L x 4” D (HG1RS3H4D-AR) (HG1RS3H5D) 3” L x 5” D (HG1RS3H5D) (HG1RS3H5D-AL) 3” L x 5” D (HG1RS3H5D-AR) (HG1RS4H4D) 4” L x 4” D (HG1RS4H4D) (HG1RS4H4D-AL) 4” L x 4” D (HG1RS4H4D-AR) STRETCH-AIR (HG1RS4H6D) 4” L x 6” D (HG1RS4H6D) (HG1RS4H6D-AL) 4” L x 6” D (HG1RS4H6D-AR) SELECTED FOR AIR TRANSMISSION & HEAT DISSIPATION. (HG1RS4H8D) 4” L x 8” D (HG1RS4H8D) (HG1RS4H8D-AL) 4” L x 8” D (HG1RS4H8D-AR) (HG1RS4H10D) 4” L x 10” D (HG1RS4H10D) (HG1RS4H10D-AL) 4” L x 10” D (HG1RS4H10D-AR) (HG1RS4H12D) 4” L x 12” D (HG1RS4H12D) (HG1RS4H12D-AL) 4” L x 12” D (HG1RS4H12D-AR) (HG1RS4H14D) 4” L x 14” D (HG1RS4H14D) (HG1RS4H14D-AL) 4” L x 14” D (HG1RS4H14D-AR) (HG1RS4H16D) 4” L x 16” D (HG1RS4H16D) (HG1RS4H16D-AL) 4” L x 16” D (HG1RS4H16D-AR) - OR - - OR - COMFORT-TEK COMFORT-TEK FABRIC Extra L COMFORT-TEK SELECTED FOR INCONTINENCE PROTECTION & AN EASILY CLEANED SURFACE. Left SIZE FABRIC Right Extra L Left SIZE Right Extra R 3” L x 4” D (HG1RF3H4D) (HG1RF3H4D-AL) 3” L x 4” D (HG1RF3H4D-AR) (HG1RF3H5D) 3” L x 5” D (HG1RF3H5D) (HG1RF3H5D-AL) 3” L x 5” D (HG1RF3H5D-AR) (HG1RF4H4D) 4” L x 4” D (HG1RF4H4D) (HG1RF4H4D-AL) 4” L x 4” D (HG1RF4H4D-AR) (HG1RF4H6D) 4” L x 6” D (HG1RF4H6D) (HG1RF4H6D-AL) 4” L x 6” D (HG1RF4H6D-AR) (HG1RF4H8D) 4” L x 8” D (HG1RF4H8D) (HG1RF4H8D-AL) 4” L x 8” D (HG1RF4H8D-AR) (HG1RF4H10D) 4” L x 10” D (HG1RF4H10D) (HG1R4H10D-AL) 4” L x 10” D (HG1RF4H10D-AR) (HG1RF4H12D) 4” L x 12” D (HG1RF4H12D) (HG1R4H12D-AL) 4” L x 12” D (HG1RF4H12D-AR) (HG1RF4H14D) 4” L x 14” D (HG1RF4H14D) (HG1R4H14D-AL) 4” L x 14” D (HG1RF4H14D-AR) (HG1RF4H16D) 4” L x 16” D (HG1RF4H16D) (HG1R4H16D-AL) 4” L x 16” D (HG1RF4H16D-AR) NOTE: Lateral thigh support hardware will allow for width adjustability. Hardware in Section A comes standard with 2 links. Each extra link in Section B allows for 1” of adjustability. LATERAL THIGH SUPPORT HARDWARE HCPCS Code: E0956 (OPTIONAL) A. Extra R (HG1RF3H4D) REMOVABLE B. FIXED - OR - MSRP $240.00/ea MSRP $100.00/ea ADDITIONAL LINK MSRP $35.00/extra link SEE DETAIL A ANGLE ADJUSTABLE ANGLE ADJUSTABLE RELEASE 5” SEE DETAIL A 5” 1” SEE DETAIL B SEE DETAIL A 5” 5” SEE DETAIL B LEFT (HGL-QR) RIGHT (HGR-QR) (1) EXTRA L (1) EXTRA R (2) EXTRA L (2) EXTRA R LEFT (HG1-LINK) RIGHT (HG1-LINK) LEFT (HGL-RS) RIGHT (HGR-RS) (1) EXTRA L (1) EXTRA R (1) EXTRA L (1) EXTRA R (2) EXTRA L (2) EXTRA R (2) EXTRA L (2) EXTRA R (3) EXTRA L (3) EXTRA R SEE DETAIL B LIBERTY® X ORDER FORM Patient Reference: SUBMIT BY EMAIL PAGE 3 of 3 LIBERTY-X-ORDER REV0316 3.2 D