Vector COMFORT-TEK FOR FLUID PROTECTION & AN EASILY CLEANED SURFACE. $ $455.00

Size: px

Start display at page:

Download "Vector COMFORT-TEK FOR FLUID PROTECTION & AN EASILY CLEANED SURFACE. $ $455.00"

Lora Owen
5 years ago
Views:

VECT LOW & VECT DER FM HCPCS CODING: E2624/E2625 ADJUSTABLE SKIN PROTECTION & POSITIONING Vector Low Vector Company Name/ACCT #: P.O. Number: Requested By: Phone: Email: Ship To: Patient Reference: Fax: 1 SIZE & STYLE F FLUID PROTECTION & AN EASILY CLEANED SURFACE.

Then email or print and fax to Customer Support at orders.comfort@permobil.com or 1.406.522.8563. *DO NOT SEND PATIENT PROTECTED HEALTH INFMATION.

VT-FL-1618 VT-FL-1718 VT-FL-1818 VT-FL-1918 VT-FL-2018 VT-FL-1617 VT-FL-1717 VT-FL-1817 VT-FL-1917 VT-FL-2017 DEPTH VT-SL-1619 VT-SL-1719 VT-SL-1819 VT-SL-1919 VT-SL-2019 VT-SL-1618 VT-SL-1718

1 VECT LOW & VECT DER FM HCPCS CODING: E2624/E2625 ADJUSTABLE SKIN PROTECTION & POSITIONING Vector Low Vector Company Name/ACCT #: P.O. Number: Requested By: Phone: Ship To: Patient Reference: Fax: 1 SIZE & STYLE F FLUID PROTECTION & AN EASILY CLEANED SURFACE. 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 or print and fax to Customer Support at orders.comfort@permobil.com or *DO NOT SEND PATIENT PROTECTED HEALTH INFMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.* F PATIENT COMFT & HEAT DISSIPATION. VECT LOW Please select size in the appropriate fabric chart below. Standard Vector found on page 2. $ $ VT-FL-1620 VT-FL-1720 VT-FL-1820 VT-FL-1920 VT-FL-2020 VT-SL-1620 VT-SL-1720 VT-SL-1820 VT-SL-1920 VT-SL-2020 DEPTH VECT-DER REV1018 VT-FL-1619 VT-FL-1719 VT-FL-1819 VT-FL-1919 VT-FL-2019 VT-FL-1618 VT-FL-1718 VT-FL-1818 VT-FL-1918 VT-FL-2018 VT-FL-1617 VT-FL-1717 VT-FL-1817 VT-FL-1917 VT-FL-2017 DEPTH VT-SL-1619 VT-SL-1719 VT-SL-1819 VT-SL-1919 VT-SL-2019 VT-SL-1618 VT-SL-1718 VT-SL-1818 VT-SL-1918 VT-SL-2018 VT-SL-1617 VT-SL-1717 VT-SL-1817 VT-SL-1917 VT-SL-2017 VT-FL-1616 VT-FL-1716 VT-FL-1816 VT-FL-1916 VT-FL-2016 VT-SL-1616 VT-SL-1716 VT-SL-1816 VT-SL-1916 VT-SL-2016 QUESTIONS? PLEASE CONTACT CUSTOMER SERVICE F ASSISTANCE VECT DER FM Patient Reference: PAGE 1 of 6 *DO NOT SEND PATIENT PROTECTED HEALTH INFMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*

2 F FLUID PROTECTION & AN EASILY CLEANED SURFACE. F PATIENT COMFT & HEAT DISSIPATION. VECT Please select size in the appropriate fabric chart below. DEPTH DEPTH $ $ VT-F-1520 VT-F-1620 VT-F-1720 VT-F-1820 VT-F-1920 VT-F-2020 VT-F-2120 VT-F-2220 VT-F-2320 VT-F-2420 VT-F-1519 VT-F-1619 VT-F-1719 VT-F-1819 VT-F-1919 VT-F-2019 VT-F-2119 VT-F-2219 VT-F-2319 VT-F-2419 VT-F-1418 VT-F-1518 VT-F-1618 VT-F-1718 VT-F-1818 VT-F-1918 VT-F-2018 VT-F-2118 VT-F-2218 VT-F-2318 VT-F-2418 VT-F-1317 VT-F-1417 VT-F-1517 VT-F-1617 VT-F-1717 VT-F-1817 VT-F-1917 VT-F-2017 VT-F-2117 VT-F-2217 VT-F-2317 VT-F-2417 VT-F-1216 VT-F-1316 VT-F-1416 VT-F-1516 VT-F-1616 VT-F-1716 VT-F-1816 VT-F-1916 VT-F-2016 VT-F-2116 VT-F-2216 VT-F-2316 VT-F-2416 VT-F-1015 VT-F-1115 VT-F-1215 VT-F-1315 VT-F-1415 VT-F-1515 VT-F-1615 VT-F-1715 VT-F-1815 VT-F-1014 VT-F-1114 VT-F-1214 VT-F-1314 VT-F-1414 VT-F-1514 VT-F-1614 VT-F-1013 VT-F-1113 VT-F-1213 VT-F-1313 VT-F-1413 VT-F-1012 VT-F-1112 VT-F-1212 VT-F-1312 VT-F-1412 VT-F-1011 VT-F-1111 VT-F-1211 VT-F-1311 VT-F-1411 VT-F-1010 VT-F-1110 VT-F-1210 VT-F-1310 VT-F $ $ VT-S-1520 VT-S-1620 VT-S-1720 VT-S-1820 VT-S-1920 VT-S-2020 VT-S-2120 VT-S-2220 VT-S-2320 VT-S-2420 VT-S-1519 VT-S-1619 VT-S-1719 VT-S-1819 VT-S-1919 VT-S-2019 VT-S-2119 VT-S-2219 VT-S-2319 VT-S-2419 VT-S-1418 VT-S-1518 VT-S-1618 VT-S-1718 VT-S-1818 VT-S-1918 VT-S-2018 VT-S-2118 VT-S-2218 VT-S-2318 VT-S-2418 VT-S-1317 VT-S-1417 VT-S-1517 VT-S-1617 VT-S-1717 VT-S-1817 VT-S-1917 VT-S-2017 VT-S-2117 VT-S-2217 VT-S-2317 VT-S-2417 VT-S-1216 VT-S-1316 VT-S-1416 VT-S-1516 VT-S-1616 VT-S-1716 VT-S-1816 VT-S-1916 VT-S-2016 VT-S-2116 VT-S-2216 VT-S-2316 VT-S-2416 VT-S-1015 VT-S-1115 VT-S-1215 VT-S-1315 VT-S-1415 VT-S-1515 VT-S-1615 VT-S-1715 VT-S-1815 VT-S-1014 VT-S-1114 VT-S-1214 VT-S-1314 VT-S-1414 VT-S-1514 VT-S-1614 VT-S-1013 VT-S-1113 VT-S-1213 VT-S-1313 VT-S-1413 VT-S-1012 VT-S-1112 VT-S-1212 VT-S-1312 VT-S-1412 VT-S-1011 VT-S-1111 VT-S-1211 VT-S-1311 VT-S-1411 VT-S-1010 VT-S-1110 VT-S-1210 VT-S-1310 VT-S QUESTIONS? PLEASE CONTACT CUSTOMER SERVICE F ASSISTANCE VECT DER FM Patient Reference: PAGE 2 of 6 *DO NOT SEND PATIENT PROTECTED HEALTH INFMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*

2 VECT ACCESSIES *All accessories are cosmetic changes to the cushion except for options in gray, which are add on items. 2.1 KWIK STRAP 2.2 INCONTINENCE LINER MSRP $16.

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.

Rear View One Extra Stretch Air Outer Cover (X-STRETCH-AIR-CV) Two Extra Stretch Air Outer Cover (2X-STRETCH-AIR-CV) One Extra Incontinence Liner (INCON-LINER) One Extra Comfort

4 SOLID SEAT PAN & HARDWARE KIT HCPCS Code: E2231 MSRP $387.00 2.5 RIGID INSERT HCPCS Code: E0992 MSRP $65.00 2.6 EXTRA VICAIR AIR CELLS MSRP $43.

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.

3 2 VECT ACCESSIES *All accessories are cosmetic changes to the cushion except for options in gray, which are add on items. 2.1 KWIK STRAP 2.2 INCONTINENCE LINER MSRP $16.00 MSRP One = $ Two = $ EXTRA COVER MSRP One = $ Two = $ 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. Liner provides extra incontinence protection for the cushion. Rear View One Extra Stretch Air Outer Cover (X-STRETCH-AIR-CV) Two Extra Stretch Air Outer Cover (2X-STRETCH-AIR-CV) One Extra Incontinence Liner (INCON-LINER) One Extra Comfort Tek Outer Cover (X-COMFT-TEK-CV) Kwik Strap (KWIK-STRAP) Two Extra Incontinence Liners (INCON-LINER) Two Extra Comfort Tek Outer Cover (2X-COMFT-TEK-CV) 2.4 SOLID SEAT PAN & HARDWARE KIT HCPCS Code: E2231 MSRP $ RIGID INSERT HCPCS Code: E0992 MSRP $ EXTRA VICAIR AIR CELLS MSRP $43.00 / 50 air cell pack 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 thigh support hardware can be easily attached. 3/ Plastic rigidizing board. Solid Seat Pan & Hardware Kit (RSSP-N-HARD) Rigid Insert Not Glued (RGD-INSERT-UNGLUED) Pack of 50 Vicair Air Cells (AIRCELL50) 2.7 VICAIR PELVIC STABILIZER MSRP $ VECT-DER REV1018 (fits) 16W x 16D -- 16W x 18D (PS-1618) (fits) 18W x 16D -- 18W x 18D (PS-1818) VECT DER FM Patient Reference: PAGE 3 of 6 *DO NOT SEND PATIENT PROTECTED HEALTH INFMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*

4 3 BODILINK LATERAL PELVIC/THIGH SUPPT HARDWARE & PADS Please select sizes in the appropriate fabric & style charts below. Contact Customer Support for custom sizes that are not listed below PREMIUM PAD SIZE & SHAPE HCPCS Code: E0953 MSRP $62.00 You may make one selection per column (Left, Extra Left, Right, and Extra Right) in section 3.1. Follow each column down to section 3.1 and select a style and cover for each pad selected in section 3.2. *Length (L) refers to the actual size dimension of the support from top to bottom edge. Depth (D) refers to the actual size dimension from anterior to posterior edge. STYLE SIZE LEFT EXTRA LEFT RIGHT EXTRA RIGHT 3.5 L x 4 D BL-LPTSP2Z-3L4D-LH BL-LPTSP2Z-3L4D-LH BL-LPTSP2Z-3L4D-RH BL-LPTSP2Z-3L4D-RH L 3.5 L x 8 D BL-LPTSP2Z-3L8D-LH BL-LPTSP2Z-3L8D-LH BL-LPTSP2Z-3L8D-RH BL-LPTSP2Z-3L8D-RH 3.5 L x 12 D BL-LPTSP2Z-3L12D-LH BL-LPTSP2Z-3L12D-LH BL-LPTSP2Z-3L12D-RH BL-LPTSP2Z-3L12D-RH D 5.5 L x 6 D BL-LPTSP2Z-5L6D-LH BL-LPTSP2Z-5L6D-LH BL-LPTSP2Z-5L6D-RH BL-LPTSP2Z-5L6D-RH 3.2 PREMIUM PAD COVER WITH FOAM INSERT COVER OPTIONS MSRP LEFT EXTRA LEFT RIGHT EXTRA RIGHT $0.00/ea. LPTS-P2-COMFT-FM LPTS-P2-COMFT-FM LPTS-P2-COMFT-FM LPTS-P2-COMFT-FM $0.00/ea. LPTS-P2-STRETCH-FM LPTS-P2-STRETCH-FM LPTS-P2-STRETCH-FM LPTS-P2-STRETCH-FM GLIDEWEAR $13.00/ea. LPTS-P2-GLIDE-FM LPTS-P2-GLIDE-FM LPTS-P2-GLIDE-FM LPTS-P2-GLIDE-FM F FLUID PROTECTION & AN EASILY CLEANED SURFACE. F PATIENT COMFT & HEAT DISSIPATION. F SKIN PROTECTION & SHEAR REDUCTION. NOT FLUID RESISTANT. 3.3 BASIC PAD SIZE & SHAPE HCPCS Code: E0953 MSRP $52.00 You may make one selection per column (Left, Extra Left, Right, and Extra Right) in section 3.3. Follow each column down to section 3.3 and select a style and cover for each pad selected in section 3.4. *Length (L) refers to the actual size dimension of the support from top to bottom edge. Depth (D) refers to the actual size dimension from anterior to posterior edge. ZERO ELEVATION ANTI-THRUST L L 3.4 BASIC PAD COVER STYLE SIZE LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT D D 3 L x 4 D BL-LPTSP1Z-3L4D-LH BL-LPTSP1Z-3L4D-LH BL-LPTSP1Z-3L4D-RH BL-LPTSP1Z-3L4D-RH 3 L x 5 D BL-LPTSP1Z-3L5D-LH BL-LPTSP1Z-3L5D-LH BL-LPTSP1Z-3L5D-RH BL-LPTSP1Z-3L5D-RH 4 L x 4 D BL-LPTSP1Z-4L4D-LH BL-LPTSP1Z-4L4D-LH BL-LPTSP1Z-4L4D-RH BL-LPTSP1Z-4L4D-RH 4 L x 6 D BL-LPTSP1Z-4L6D-LH BL-LPTSP1Z-4L6D-LH BL-LPTSP1Z-4L6D-RH BL-LPTSP1Z-4L6D-RH 4 L x 8 D BL-LPTSP1Z-4L8D-LH BL-LPTSP1Z-4L8D-LH BL-LPTSP1Z-4L8D-RH BL-LPTSP1Z-4L8D-RH 4 L x 10 D BL-LPTSP1Z-4L10D-LH BL-LPTSP1Z-4L10D-LH BL-LPTSP1Z-4L10D-RH BL-LPTSP1Z-4L10D-RH 4 L x 12 D BL-LPTSP1Z-4L12D-LH BL-LPTSP1Z-4L12D-LH BL-LPTSP1Z-4L12D-RH BL-LPTSP1Z-4L12D-RH 4 L x 14 D BL-LPTSP1Z-4L14D-LH BL-LPTSP1Z-4L14D-LH BL-LPTSP1Z-4L14D-RH BL-LPTSP1Z-4L14D-RH 4 L x D BL-LPTSP1Z-4L16D-LH BL-LPTSP1Z-4L16D-LH BL-LPTSP1Z-4L16D-RH BL-LPTSP1Z-4L16D-RH 5 L x 7 D BL-LPTSP1Z-5L7D-LH BL-LPTSP1Z-5L7D-LH BL-LPTSP1Z-5L7D-RH BL-LPTSP1Z-5L7D-RH 3 L x 4 D BL-LPTSP1A-3L4D-LH BL-LPTSP1A-3L4D-LH BL-LPTSP1A-3L4D-RH BL-LPTSP1A-3L4D-RH 3 L x 5 D BL-LPTSP1A-3L5D-LH BL-LPTSP1A-3L5D-LH BL-LPTSP1A-3L5D-RH BL-LPTSP1A-3L5D-RH 4 L x 4 D BL-LPTSP1A-4L4D-LH BL-LPTSP1A-4L4D-LH BL-LPTSP1A-4L4D-RH BL-LPTSP1A-4L4D-RH 4 L x 6 D BL-LPTSP1A-4L6D-LH BL-LPTSP1A-4L6D-LH BL-LPTSP1A-4L6D-RH BL-LPTSP1A-4L6D-RH 4 L x 8 D BL-LPTSP1A-4L8D-LH BL-LPTSP1A-4L8D-LH BL-LPTSP1A-4L8D-RH BL-LPTSP1A-4L8D-RH 4 L x 10 D BL-LPTSP1A-4L10D-LH BL-LPTSP1A-4L10D-LH BL-LPTSP1A-4L10D-RH BL-LPTSP1A-4L10D-RH 4 L x 12 D BL-LPTSP1A-4L12D-LH BL-LPTSP1A-4L12D-LH BL-LPTSP1A-4L12D-RH BL-LPTSP1A-4L12D-RH 4 L x 14 D BL-LPTSP1A-4L14D-LH BL-LPTSP1A-4L14D-LH BL-LPTSP1A-4L14D-RH BL-LPTSP1A-4L14D-RH 4 L x D BL-LPTSP1A-4L16D-LH BL-LPTSP1A-4L16D-LH BL-LPTSP1A-4L16D-RH BL-LPTSP1A-4L16D-RH 5 L x 7 D BL-LPTSP1A-5L7D-LH BL-LPTSP1A-5L7D-LH BL-LPTSP1A-5L7D-RH BL-LPTSP1A-5L7D-RH F FLUID PROTECTION & AN EASILY CLEANED SURFACE. F PATIENT COMFT & HEAT DISSIPATION. COVER OPTIONS MSRP LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT F SKIN PROTECTION & SHEAR REDUCTION. NOT FLUID RESISTANT. VECT-DER REV1018 $0.00/ea. LPTS-P1-COMFT LPTS-P1-COMFT LPTS-P1-COMFT LPTS-P1-COMFT $0.00/ea. LPTS-P1-STRETCH LPTS-P1-STRETCH LPTS-P1-STRETCH LPTS-P1-STRETCH GLIDEWEAR $13.00/ea. LPTS-P1-GLIDE LPTS-P1-GLIDE LPTS-P1-GLIDE LPTS-P1-GLIDE VECT DER FM Patient Reference: PAGE 4 of 6 *DO NOT SEND PATIENT PROTECTED HEALTH INFMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*

3.5 A. BODILINK LATERAL PELVIC/ THIGH SUPPT HARDWARE, SLOT MOUNT SLOT MOUNT- FIXED SLOT MOUNT- 2.0-3.0 You may make one selection per column (Left, Extra Left, Right, and Extra Right) in section 3.

0-6.5 SMALL MEDIUM LARGE MAX CUSHION CLEARANCE RECOMMENDED CUSHION SMALL 3.0 2.0-3.0 MEDIUM 4.5 3.0-4.5 LARGE 6.5 4.0-6.5 SIZE MSRP LEFT EXTRA LEFT RIGHT EXTRA RIGHT SMALL $141.

00 BL-LPTS-TT1FXSL3-LH BL-LPTS-TT1FXSL3-LH BL-LPTS-TT1FXSL3-RH BL-LPTS-TT1FXSL3-RH E1028 SMALL $248.00 BL-LPTS-TT1RMSL1-LH BL-LPTS-TT1RMSL1-LH BL-LPTS-TT1RMSL1-RH BL-LPTS-TT1RMSL1-RH MEDIUM $248.

CUSHION POWER MOUNT- FIXED POWER MOUNT- 2.0-3.5 3.0-5.5 4.0-7.5 MAX CUSHION CLEARANCE RECOMMENDED CUSHION SMALL 3.5 2.0-3.5 MEDIUM 5.5 3.0-5.5 LARGE 7.5 4.0-7.5 SMALL MEDIUM LARGE SIZE MSRP LEFT EXTRA LEFT RIGHT EXTRA RIGHT SMALL $185.

00 BL-LPTS-TT1FXPWL2-LH BL-LPTS-TT1FXPWL2-LH BL-LPTS-TT1FXPWL2-RH BL-LPTS-TT1FXPWL2-RH LARGE $185.

5 3.5 A. BODILINK LATERAL PELVIC/ THIGH SUPPT HARDWARE, SLOT MOUNT SLOT MOUNT- FIXED SLOT MOUNT You may make one selection per column (Left, Extra Left, Right, and Extra Right) in section 3.5 from group A, B, -- C. TT long extention arms (section 3.6) will only work with TT style hardware. GT hardware extra links (section 3.6) will only work with GT style hardware. VS. CUSHION SMALL MEDIUM LARGE MAX CUSHION CLEARANCE RECOMMENDED CUSHION SMALL MEDIUM LARGE SIZE MSRP LEFT EXTRA LEFT RIGHT EXTRA RIGHT SMALL $ BL-LPTS-TT1FXSL1-LH BL-LPTS-TT1FXSL1-LH BL-LPTS-TT1FXSL1-RH BL-LPTS-TT1FXSL1-RH FIXED MEDIUM $ BL-LPTS-TT1FXSL2-LH BL-LPTS-TT1FXSL2-LH BL-LPTS-TT1FXSL2-RH BL-LPTS-TT1FXSL2-RH LARGE $ BL-LPTS-TT1FXSL3-LH BL-LPTS-TT1FXSL3-LH BL-LPTS-TT1FXSL3-RH BL-LPTS-TT1FXSL3-RH E1028 SMALL $ BL-LPTS-TT1RMSL1-LH BL-LPTS-TT1RMSL1-LH BL-LPTS-TT1RMSL1-RH BL-LPTS-TT1RMSL1-RH MEDIUM $ BL-LPTS-TT1RMSL2-LH BL-LPTS-TT1RMSL2-LH BL-LPTS-TT1RMSL2-RH BL-LPTS-TT1RMSL2-RH LARGE $ BL-LPTS-TT1RMSL3-LH BL-LPTS-TT1RMSL3-LH BL-LPTS-TT1RMSL3-RH BL-LPTS-TT1RMSL3-RH B., POWER MOUNT VS. CUSHION POWER MOUNT- FIXED POWER MOUNT MAX CUSHION CLEARANCE RECOMMENDED CUSHION SMALL MEDIUM LARGE SMALL MEDIUM LARGE SIZE MSRP LEFT EXTRA LEFT RIGHT EXTRA RIGHT SMALL $ BL-LPTS-TT1FXPWL1-LH BL-LPTS-TT1FXPWL1-LH BL-LPTS-TT1FXPWL1-RH BL-LPTS-TT1FXPWL1-RH FIXED MEDIUM $ BL-LPTS-TT1FXPWL2-LH BL-LPTS-TT1FXPWL2-LH BL-LPTS-TT1FXPWL2-RH BL-LPTS-TT1FXPWL2-RH LARGE $ BL-LPTS-TT1FXPWL3-LH BL-LPTS-TT1FXPWL3-LH BL-LPTS-TT1FXPWL3-RH BL-LPTS-TT1FXPWL3-RH E1028 SMALL $ BL-LPTS-TT1RMPWL1-LH BL-LPTS-TT1RMPWL1-LH BL-LPTS-TT1RMPWL1-RH BL-LPTS-TT1RMPWL1-RH MEDIUM $ BL-LPTS-TT1RMPWL2-LH BL-LPTS-TT1RMPWL2-LH BL-LPTS-TT1RMPWL2-RH BL-LPTS-TT1RMPWL2-RH LARGE $ BL-LPTS-TT1RMPWL3-LH BL-LPTS-TT1RMPWL3-LH BL-LPTS-TT1RMPWL3-RH BL-LPTS-TT1RMPWL3-RH, POWER MOUNT OPTION NOTE: If choosing the Power Mount Hardware, choose the appropriate power mount type below. POWER MOUNT MSRP PART NUMBER QUANTUM add $0.00 LPTS-TT1-PW1 PERMOBIL add $0.00 LPTS-TT1-PW2 QUICKIE add $0.00 LPTS-TT1-PW3 VECT-DER REV1018 ROVI add $0.00 LPTS-TT1-PW4 AVID REHAB add $0.00 LPTS-TT1-PW5 VECT DER FM Patient Reference: PAGE 5 of 6 *DO NOT SEND PATIENT PROTECTED HEALTH INFMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*

C. GT HARDWARE (ONLY SLOT MOUNT) GT HARDWARE SLOT MOUNT- FIXED GT HARDWARE SLOT MOUNT- NO MEDIAL 1 MEDIAL HARDWARE MAX CUSHION CLEARANCE

0 *If you need to increase the height or medial reach, add additional links in section 2.

00 BL-LPTS-GT2FXS-LH BL-LPTS-GT2FXS-LH BL-LPTS-GT2FXS-RH BL-LPTS-GT2FXS-RH E1028 $226.

6 ADDITIONAL OPTIONS TT LONG EXTENSION ARM 4 LEFT EXTRA LEFT RIGHT EXTRA RIGHT MSRP $37.

6 C. GT HARDWARE (ONLY SLOT MOUNT) GT HARDWARE SLOT MOUNT- FIXED GT HARDWARE SLOT MOUNT- NO MEDIAL 1 MEDIAL HARDWARE MAX CUSHION CLEARANCE RECOMMENDED CUSHION NO MEDIAL * MEDIAL * *If you need to increase the height or medial reach, add additional links in section 2.2. SIZE MSRP LEFT EXTRA LEFT RIGHT EXTRA RIGHT FIXED $ BL-LPTS-GT2FXS-LH BL-LPTS-GT2FXS-LH BL-LPTS-GT2FXS-RH BL-LPTS-GT2FXS-RH E1028 $ BL-LPTS-GT2RMS-LH BL-LPTS-GT2RMS-LH BL-LPTS-GT2RMS-RH BL-LPTS-GT2RMS-RH 3.6 ADDITIONAL OPTIONS TT LONG EXTENSION ARM 4 LEFT EXTRA LEFT RIGHT EXTRA RIGHT MSRP $37.00/arm BL-LPTS-TT1LARM4 BL-LPTS-TT1LARM4 BL-LPTS-TT1LARM4 BL-LPTS-TT1LARM4 GT ADDITIONAL HARDWARE LINKS VECT-DER REV1018 MSRP $37.00/link (2 Additional 1.25 Links Allowed Per Hardware Ordered) LEFT EXTRA LEFT RIGHT EXTRA RIGHT BL-LPTS-GT2LINK BL-LPTS-GT2LINK BL-LPTS-GT2LINK BL-LPTS-GT2LINK BL-LPTS-GT2LINK BL-LPTS-GT2LINK BL-LPTS-GT2LINK BL-LPTS-GT2LINK VECT DER FM Patient Reference: SUBMIT BY PAGE 6 of 6 *DO NOT SEND PATIENT PROTECTED HEALTH INFMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*

$ $ QUESTIONS? PLEASE CONTACT CUSTOMER SERVICE FOR ASSISTANCE

$ $ QUESTIONS? PLEASE CONTACT CUSTOMER SERVICE FOR ASSISTANCE ADJUSTER LOW & ADJUSTER DER FM HCPCS CODING: E2622/E2623 - ADJUSTABLE SKIN PROTECTION Adjuster Low Adjuster Company Name/ACCT #: P.O. Number: Requested By: Phone: Email: Ship To: Patient Reference: Fax: