DEPTH DEPTH. QUESTIONS? PLEASE CONTACT CUSTOMER SERVICE FOR ASSISTANCE Liberty X is not recommended for use in altitudes above 3,000 ft.
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- Myra Brooks
- 5 years ago
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1 IBERTY X ER FM HCPCS COING: E2622 AJUSTABE SKIN PROTECTION iberty X shown with GlideWear iberty X iner and Foam Base Company Name/ACCT #: P.O. Number: Requested By: Phone: Fax: Ship To: Patient Reference: 1 SIZE & STYE 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 *O NOT SEN PATIENT PROTECTE HEATH INFMATION. IT IS NOT NEEE TO MAKE THE PROUCT YOU ARE REQUESTING.* Please select size in the appropriate fabric chart below. F FUI PROTECTION & AN EASIY CEANE SURFACE. F PATIENT COMFT & HEAT ISSIPATION. $ $ BX-F-1820 BX-F-2020 BX-S-1820 BX-S-2020 BX-F-1618 BX-F-1818 BX-F-2018 BX-F-1717 BX-S-1618 BX-S-1818 BX-S-2018 BX-S-1717 BX-F-1616 BX-F-1816 BX-S-1616 BX-S-1816 IBERTY X with GIEWEAR 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. GIEWEAR Patent No. 8,646,459 with GIEWEAR with GIEWEAR $ $ BX-FQ-1820 BX-FQ-2020 BX-FQ-1618 BX-FQ-1818 BX-FQ-2018 BX-FQ-1717 BX-FQ-1616 BX-FQ-1816 BX-SQ-1820 BX-SQ-2020 BX-SQ-1618 BX-SQ-1818 BX-SQ-2018 BX-SQ-1717 BX-SQ-1616 BX-SQ-1816 IBERTY X-ER REV1018 QUESTIONS? PEASE CONTACT CUSTOMER SERVICE F ASSISTANCE iberty X is not recommended for use in altitudes above 3,000 ft. IBERTY X ER FM Patient Reference: PAGE 1 of 5 *O NOT SEN PATIENT PROTECTE HEATH INFMATION. IT IS NOT NEEE TO MAKE THE PROUCT YOU ARE REQUESTING.*
2 2 IBERTY X ACCESSIES *All accessories are cosmetic changes to the cushion except for options in gray, which are add on items. 2.1 CO - COMES STANAR W/ REFECTIVE BUE PIPING MSRP $ KWIK STRAP MSRP $ INCONTINENCE INER MSRP One = $ Two = $ 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 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. iner provides extra incontinence protection for the cushion. Rear View CO OCATION Red (RE) Silver Reflective (SIVER) One Extra Incontinence iner (INCON-INER) Purple (PURPE) Pink (PINK) Green (GREEN) Remove (REMOVE) Kwik Strap (KWIK-STRAP) Two Extra Incontinence iners (INCON-INER) Orange (ANGE) 2.4 EXTRA COVER MSRP One = $ Two = $ REMOVABE SOI SEAT PAN & HARWARE KIT HCPCS Code: E2231 MSRP $ RIGI INSERT HCPCS Code: E0992 MSRP $65.00 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. ateral thigh support hardware can be easily attached. 3/ 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-COMFT-TEK-CV) Two Extra Comfort Tek Outer Cover (2X-COMFT-TEK-CV) Solid Seat Pan & Hardware Kit (RSSP-N-HAR) Rigid Insert Not Glued (RG-INSERT-UNGUE) 2.7 VICAIR PEVIC STABIIZER MSRP $ IBERTY X-ER REV1018 (fits) 16W x W x 18 (PS-1618) (fits) 18W x W x 18 (PS-1818) IBERTY X ER FM Patient Reference: PAGE 2 of 5 *O NOT SEN PATIENT PROTECTE HEATH INFMATION. IT IS NOT NEEE TO MAKE THE PROUCT YOU ARE REQUESTING.*
3 3 BOIINK ATERA PEVIC/THIGH SUPPT HARWARE & PAS Please select sizes in the appropriate fabric & style charts below. Contact Customer Support for custom sizes that are not listed below PREMIUM PA SIZE & SHAPE HCPCS Code: E0953 MSRP $62.00 You may make one selection per column (eft, Extra eft, 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. *ength () refers to the actual size dimension of the support from top to bottom edge. epth () refers to the actual size dimension from anterior to posterior edge. STYE SIZE EFT EXTRA EFT RIGHT EXTRA RIGHT 3.5 x 4 B-PTSP2Z-34-H B-PTSP2Z-34-H B-PTSP2Z-34-RH B-PTSP2Z-34-RH 3.5 x 8 B-PTSP2Z-38-H B-PTSP2Z-38-H B-PTSP2Z-38-RH B-PTSP2Z-38-RH 3.5 x 12 B-PTSP2Z-312-H B-PTSP2Z-312-H B-PTSP2Z-312-RH B-PTSP2Z-312-RH 5.5 x 6 B-PTSP2Z-56-H B-PTSP2Z-56-H B-PTSP2Z-56-RH B-PTSP2Z-56-RH 3.2 PREMIUM PA COVER WITH FOAM INSERT COVER OPTIONS MSRP EFT EXTRA EFT RIGHT EXTRA RIGHT $0.00/ea. PTS-P2-COMFT-FM PTS-P2-COMFT-FM PTS-P2-COMFT-FM PTS-P2-COMFT-FM $0.00/ea. PTS-P2-STRETCH-FM PTS-P2-STRETCH-FM PTS-P2-STRETCH-FM PTS-P2-STRETCH-FM GIEWEAR $13.00/ea. PTS-P2-GIE-FM PTS-P2-GIE-FM PTS-P2-GIE-FM PTS-P2-GIE-FM F FUI PROTECTION & AN EASIY CEANE SURFACE. F PATIENT COMFT & HEAT ISSIPATION. F SKIN PROTECTION & SHEAR REUCTION. NOT FUI RESISTANT. 3.3 BASIC PA SIZE & SHAPE HCPCS Code: E0953 MSRP $52.00 You may make one selection per column (eft, Extra eft, 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. *ength () refers to the actual size dimension of the support from top to bottom edge. epth () refers to the actual size dimension from anterior to posterior edge. ZERO EEVATION ANTI-THRUST 3.4 BASIC PA COVER STYE SIZE EFT *EXTRA EFT RIGHT *EXTRA RIGHT 3 x 4 B-PTSP1Z-34-H B-PTSP1Z-34-H B-PTSP1Z-34-RH B-PTSP1Z-34-RH 3 x 5 B-PTSP1Z-35-H B-PTSP1Z-35-H B-PTSP1Z-35-RH B-PTSP1Z-35-RH 4 x 4 B-PTSP1Z-44-H B-PTSP1Z-44-H B-PTSP1Z-44-RH B-PTSP1Z-44-RH 4 x 6 B-PTSP1Z-46-H B-PTSP1Z-46-H B-PTSP1Z-46-RH B-PTSP1Z-46-RH 4 x 8 B-PTSP1Z-48-H B-PTSP1Z-48-H B-PTSP1Z-48-RH B-PTSP1Z-48-RH 4 x 10 B-PTSP1Z-410-H B-PTSP1Z-410-H B-PTSP1Z-410-RH B-PTSP1Z-410-RH 4 x 12 B-PTSP1Z-412-H B-PTSP1Z-412-H B-PTSP1Z-412-RH B-PTSP1Z-412-RH 4 x 14 B-PTSP1Z-414-H B-PTSP1Z-414-H B-PTSP1Z-414-RH B-PTSP1Z-414-RH 4 x B-PTSP1Z-416-H B-PTSP1Z-416-H B-PTSP1Z-416-RH B-PTSP1Z-416-RH 5 x 7 B-PTSP1Z-57-H B-PTSP1Z-57-H B-PTSP1Z-57-RH B-PTSP1Z-57-RH 3 x 4 B-PTSP1A-34-H B-PTSP1A-34-H B-PTSP1A-34-RH B-PTSP1A-34-RH 3 x 5 B-PTSP1A-35-H B-PTSP1A-35-H B-PTSP1A-35-RH B-PTSP1A-35-RH 4 x 4 B-PTSP1A-44-H B-PTSP1A-44-H B-PTSP1A-44-RH B-PTSP1A-44-RH 4 x 6 B-PTSP1A-46-H B-PTSP1A-46-H B-PTSP1A-46-RH B-PTSP1A-46-RH 4 x 8 B-PTSP1A-48-H B-PTSP1A-48-H B-PTSP1A-48-RH B-PTSP1A-48-RH 4 x 10 B-PTSP1A-410-H B-PTSP1A-410-H B-PTSP1A-410-RH B-PTSP1A-410-RH 4 x 12 B-PTSP1A-412-H B-PTSP1A-412-H B-PTSP1A-412-RH B-PTSP1A-412-RH 4 x 14 B-PTSP1A-414-H B-PTSP1A-414-H B-PTSP1A-414-RH B-PTSP1A-414-RH 4 x B-PTSP1A-416-H B-PTSP1A-416-H B-PTSP1A-416-RH B-PTSP1A-416-RH 5 x 7 B-PTSP1A-57-H B-PTSP1A-57-H B-PTSP1A-57-RH B-PTSP1A-57-RH F FUI PROTECTION & AN EASIY CEANE SURFACE. F PATIENT COMFT & HEAT ISSIPATION. COVER OPTIONS MSRP EFT *EXTRA EFT RIGHT *EXTRA RIGHT F SKIN PROTECTION & SHEAR REUCTION. NOT FUI RESISTANT. IBERTY X-ER REV1018 $0.00/ea. PTS-P1-COMFT PTS-P1-COMFT PTS-P1-COMFT PTS-P1-COMFT $0.00/ea. PTS-P1-STRETCH PTS-P1-STRETCH PTS-P1-STRETCH PTS-P1-STRETCH GIEWEAR $13.00/ea. PTS-P1-GIE PTS-P1-GIE PTS-P1-GIE PTS-P1-GIE IBERTY X ER FM Patient Reference: PAGE 3 of 5 *O NOT SEN PATIENT PROTECTE HEATH INFMATION. IT IS NOT NEEE TO MAKE THE PROUCT YOU ARE REQUESTING.*
4 3.5 A. BOIINK ATERA PEVIC/ THIGH SUPPT HARWARE TT HARWARE, SOT MOUNT TT HARWARE SOT MOUNT- FIXE TT HARWARE SOT MOUNT- REMOVABE You may make one selection per column (eft, Extra eft, 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. HARWARE SIZE VS SMA MEIUM ARGE HARWARE SIZE CEARANCE RECOMMENE SMA MEIUM ARGE SIZE MSRP EFT EXTRA EFT RIGHT EXTRA RIGHT SMA $ B-PTS-TT1FXS1-H B-PTS-TT1FXS1-H B-PTS-TT1FXS1-RH B-PTS-TT1FXS1-RH FIXE MEIUM $ B-PTS-TT1FXS2-H B-PTS-TT1FXS2-H B-PTS-TT1FXS2-RH B-PTS-TT1FXS2-RH ARGE $ B-PTS-TT1FXS3-H B-PTS-TT1FXS3-H B-PTS-TT1FXS3-RH B-PTS-TT1FXS3-RH REMOVABE SMA $ B-PTS-TT1RMS1-H B-PTS-TT1RMS1-H B-PTS-TT1RMS1-RH B-PTS-TT1RMS1-RH MEIUM $ B-PTS-TT1RMS2-H B-PTS-TT1RMS2-H B-PTS-TT1RMS2-RH B-PTS-TT1RMS2-RH ARGE $ B-PTS-TT1RMS3-H B-PTS-TT1RMS3-H B-PTS-TT1RMS3-RH B-PTS-TT1RMS3-RH B. TT HARWARE, POWER MOUNT HARWARE SIZE VS. TT HARWARE POWER MOUNT- FIXE TT HARWARE POWER MOUNT- REMOVABE HARWARE SIZE CEARANCE RECOMMENE SMA MEIUM ARGE SMA MEIUM ARGE SIZE MSRP EFT EXTRA EFT RIGHT EXTRA RIGHT SMA $ B-PTS-TT1FXPW1-H B-PTS-TT1FXPW1-H B-PTS-TT1FXPW1-RH B-PTS-TT1FXPW1-RH FIXE MEIUM $ B-PTS-TT1FXPW2-H B-PTS-TT1FXPW2-H B-PTS-TT1FXPW2-RH B-PTS-TT1FXPW2-RH ARGE $ B-PTS-TT1FXPW3-H B-PTS-TT1FXPW3-H B-PTS-TT1FXPW3-RH B-PTS-TT1FXPW3-RH REMOVABE SMA $ B-PTS-TT1RMPW1-H B-PTS-TT1RMPW1-H B-PTS-TT1RMPW1-RH B-PTS-TT1RMPW1-RH MEIUM $ B-PTS-TT1RMPW2-H B-PTS-TT1RMPW2-H B-PTS-TT1RMPW2-RH B-PTS-TT1RMPW2-RH ARGE $ B-PTS-TT1RMPW3-H B-PTS-TT1RMPW3-H B-PTS-TT1RMPW3-RH B-PTS-TT1RMPW3-RH TT HARWARE, 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 PTS-TT1-PW1 PERMOBI add $0.00 PTS-TT1-PW2 QUICKIE add $0.00 PTS-TT1-PW3 IBERTY X-ER REV1018 ROVI add $0.00 PTS-TT1-PW4 AVI REHAB add $0.00 PTS-TT1-PW5 IBERTY X ER FM Patient Reference: PAGE 4 of 5 *O NOT SEN PATIENT PROTECTE HEATH INFMATION. IT IS NOT NEEE TO MAKE THE PROUCT YOU ARE REQUESTING.*
5 C. GT HARWARE (ONY SOT MOUNT) GT HARWARE SOT MOUNT- FIXE GT HARWARE SOT MOUNT- REMOVABE NO MEIA 1 MEIA HARWARE CEARANCE RECOMMENE NO MEIA * MEIA * *If you need to increase the height or medial reach, add additional links in section 2.2. SIZE MSRP EFT EXTRA EFT RIGHT EXTRA RIGHT FIXE $ B-PTS-GT2FXS-H B-PTS-GT2FXS-H B-PTS-GT2FXS-RH B-PTS-GT2FXS-RH REMOVABE $ B-PTS-GT2RMS-H B-PTS-GT2RMS-H B-PTS-GT2RMS-RH B-PTS-GT2RMS-RH 3.6 AITIONA OPTIONS TT ONG EXTENSION ARM 4 EFT EXTRA EFT RIGHT EXTRA RIGHT MSRP $37.00/arm B-PTS-TT1ARM4 B-PTS-TT1ARM4 B-PTS-TT1ARM4 B-PTS-TT1ARM4 GT AITIONA HARWARE INKS IBERTY X-ER REV1018 MSRP $37.00/link (2 Additional 1.25 inks Allowed Per Hardware Ordered) EFT EXTRA EFT RIGHT EXTRA RIGHT B-PTS-GT2INK B-PTS-GT2INK B-PTS-GT2INK B-PTS-GT2INK B-PTS-GT2INK B-PTS-GT2INK B-PTS-GT2INK B-PTS-GT2INK IBERTY X ER FM Patient Reference: SUBMIT BY EMAI PAGE 5 of 5 *O NOT SEN PATIENT PROTECTE HEATH INFMATION. IT IS NOT NEEE TO MAKE THE PROUCT YOU ARE REQUESTING.*
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