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: 1 SIZE & STYLE 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 Support at orders.comfort@permobil.com or 1.406.522.8563. *DO NOT SEND PATIENT PROTECTED HEALTH INFMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.* F FLUID PROTECTION & AN EASILY CLEANED SURFACE. F PATIENT COMFT & HEAT DISSIPATION. ADJUSTER LOW Please select size in the appropriate fabric chart below. Standard Adjuster found on page 2. $455.00 $455.00 AJ-FL-1620 AJ-FL-1720 AJ-FL-1820 AJ-FL-1920 AJ-FL-2020 AJ-SL-1620 AJ-SL-1720 AJ-SL-1820 AJ-SL-1920 AJ-SL-2020 DEPTH ADJUSTER-DER REV1018 AJ-FL-1619 AJ-FL-1719 AJ-FL-1819 AJ-FL-1919 AJ-FL-2019 AJ-FL-1618 AJ-FL-1718 AJ-FL-1818 AJ-FL-1918 AJ-FL-2018 AJ-FL-1617 AJ-FL-1717 AJ-FL-1817 AJ-FL-1917 AJ-FL-2017 DEPTH AJ-SL-1619 AJ-SL-1719 AJ-SL-1819 AJ-SL-1919 AJ-SL-2019 AJ-SL-1618 AJ-SL-1718 AJ-SL-1818 AJ-SL-1918 AJ-SL-2018 AJ-SL-1617 AJ-SL-1717 AJ-SL-1817 AJ-SL-1917 AJ-SL-2017 AJ-FL-1616 AJ-FL-1716 AJ-FL-1816 AJ-FL-1916 AJ-FL-2016 AJ-SL-1616 AJ-SL-1716 AJ-SL-1816 AJ-SL-1916 AJ-SL-2016 QUESTIONS? PLEASE CONTACT CUSTOMER SERVICE F ASSISTANCE. 800.564.9248 ADJUSTER 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.*
F FLUID PROTECTION & AN EASILY CLEANED SURFACE. F PATIENT COMFT & HEAT DISSIPATION. ADJUSTER-DER REV1018 ADJUSTER Please select size in the appropriate fabric chart below. DEPTH DEPTH 15 14 13 12 11 10 15 14 13 12 11 10 $455.00 $503.00 AJ-F-1520 AJ-F-1620 AJ-F-1720 AJ-F-1820 AJ-F-1920 AJ-F-2020 AJ-F-2120 AJ-F-2220 AJ-F-2320 AJ-F-2420 AJ-F-1519 AJ-F-1619 AJ-F-1719 AJ-F-1819 AJ-F-1919 AJ-F-2019 AJ-F-2119 AJ-F-2219 AJ-F-2319 AJ-F-2419 AJ-F-1418 AJ-F-1518 AJ-F-1618 AJ-F-1718 AJ-F-1818 AJ-F-1918 AJ-F-2018 AJ-F-2118 AJ-F-2218 AJ-F-2318 AJ-F-2418 AJ-F-1317 AJ-F-1417 AJ-F-1517 AJ-F-1617 AJ-F-1717 AJ-F-1817 AJ-F-1917 AJ-F-2017 AJ-F-2117 AJ-F-2217 AJ-F-2317 AJ-F-2417 AJ-F-1216 AJ-F-1316 AJ-F-1416 AJ-F-1516 AJ-F-1616 AJ-F-1716 AJ-F-1816 AJ-F-1916 AJ-F-2016 AJ-F-2116 AJ-F-2216 AJ-F-2316 AJ-F-2416 AJ-F-1015 AJ-F-1115 AJ-F-1215 AJ-F-1315 AJ-F-1415 AJ-F-1515 AJ-F-1615 AJ-F-1715 AJ-F-1815 AJ-F-1014 AJ-F-1114 AJ-F-1214 AJ-F-1314 AJ-F-1414 AJ-F-1514 AJ-F-1614 AJ-F-1013 AJ-F-1113 AJ-F-1213 AJ-F-1313 AJ-F-1413 AJ-F-1012 AJ-F-1112 AJ-F-1212 AJ-F-1312 AJ-F-1412 AJ-F-1011 AJ-F-1111 AJ-F-1211 AJ-F-1311 AJ-F-1411 AJ-F-1010 AJ-F-1110 AJ-F-1210 AJ-F-1310 AJ-F-1410 10 11 12 13 14 15 21 22 23 24 $455.00 $503.00 AJ-S-1520 AJ-S-1620 AJ-S-1720 AJ-S-1820 AJ-S-1920 AJ-S-2020 AJ-S-2120 AJ-S-2220 AJ-S-2320 AJ-S-2420 AJ-S-1519 AJ-S-1619 AJ-S-1719 AJ-S-1819 AJ-S-1919 AJ-S-2019 AJ-S-2119 AJ-S-2219 AJ-S-2319 AJ-S-2419 AJ-S-1418 AJ-S-1518 AJ-S-1618 AJ-S-1718 AJ-S-1818 AJ-S-1918 AJ-S-2018 AJ-S-2118 AJ-S-2218 AJ-S-2318 AJ-S-2418 AJ-S-1317 AJ-S-1417 AJ-S-1517 AJ-S-1617 AJ-S-1717 AJ-S-1817 AJ-S-1917 AJ-S-2017 AJ-S-2117 AJ-S-2217 AJ-S-2317 AJ-S-2417 AJ-S-1216 AJ-S-1316 AJ-S-1416 AJ-S-1516 AJ-S-1616 AJ-S-1716 AJ-S-1816 AJ-S-1916 AJ-S-2016 AJ-S-2116 AJ-S-2216 AJ-S-2316 AJ-S-2416 AJ-S-1015 AJ-S-1115 AJ-S-1215 AJ-S-1315 AJ-S-1415 AJ-S-1515 AJ-S-1615 AJ-S-1715 AJ-S-1815 AJ-S-1014 AJ-S-1114 AJ-S-1214 AJ-S-1314 AJ-S-1414 AJ-S-1514 AJ-S-1614 AJ-S-1013 AJ-S-1113 AJ-S-1213 AJ-S-1313 AJ-S-1413 AJ-S-1012 AJ-S-1112 AJ-S-1212 AJ-S-1312 AJ-S-1412 AJ-S-1011 AJ-S-1111 AJ-S-1211 AJ-S-1311 AJ-S-1411 AJ-S-1010 AJ-S-1110 AJ-S-1210 AJ-S-1310 AJ-S-1410 10 11 12 13 14 15 21 22 23 24 QUESTIONS? PLEASE CONTACT CUSTOMER SERVICE F ASSISTANCE. 800.564.9248 ADJUSTER 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 ADJUSTER 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 = $60.00 - Two = $120.00 2.3 EXTRA COVER MSRP One = $62.00 - Two = $124.00 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 $387.00 2.5 RIGID INSERT HCPCS Code: E0992 MSRP $65.00 2.6 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 $118.00 ADJUSTER-DER REV1018 (fits) 16W x 16D -- 16W x 18D (PS-1618) (fits) 18W x 16D -- 18W x 18D (PS-1818) ADJUSTER 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.*
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. 1.800.564.9248. 3.1 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 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 3.4 BASIC PAD COVER F FLUID PROTECTION & AN EASILY CLEANED SURFACE. F PATIENT COMFT & HEAT DISSIPATION. COVER OPTIONS MSRP LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT $0.00/ea. LPTS-P1-COMFT LPTS-P1-COMFT LPTS-P1-COMFT LPTS-P1-COMFT F SKIN PROTECTION & SHEAR REDUCTION. NOT FLUID RESISTANT. ADJUSTER-DER REV1018 $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 ADJUSTER 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 3.5 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 3.0-4.5 4.0-6.5 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-TT1FXSL1-LH BL-LPTS-TT1FXSL1-LH BL-LPTS-TT1FXSL1-RH BL-LPTS-TT1FXSL1-RH FIXED MEDIUM $141.00 BL-LPTS-TT1FXSL2-LH BL-LPTS-TT1FXSL2-LH BL-LPTS-TT1FXSL2-RH BL-LPTS-TT1FXSL2-RH LARGE $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 $248.00 BL-LPTS-TT1RMSL2-LH BL-LPTS-TT1RMSL2-LH BL-LPTS-TT1RMSL2-RH BL-LPTS-TT1RMSL2-RH LARGE $248.00 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- 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-TT1FXPWL1-LH BL-LPTS-TT1FXPWL1-LH BL-LPTS-TT1FXPWL1-RH BL-LPTS-TT1FXPWL1-RH FIXED MEDIUM $185.00 BL-LPTS-TT1FXPWL2-LH BL-LPTS-TT1FXPWL2-LH BL-LPTS-TT1FXPWL2-RH BL-LPTS-TT1FXPWL2-RH LARGE $185.00 BL-LPTS-TT1FXPWL3-LH BL-LPTS-TT1FXPWL3-LH BL-LPTS-TT1FXPWL3-RH BL-LPTS-TT1FXPWL3-RH E1028 SMALL $285.00 BL-LPTS-TT1RMPWL1-LH BL-LPTS-TT1RMPWL1-LH BL-LPTS-TT1RMPWL1-RH BL-LPTS-TT1RMPWL1-RH MEDIUM $285.00 BL-LPTS-TT1RMPWL2-LH BL-LPTS-TT1RMPWL2-LH BL-LPTS-TT1RMPWL2-RH BL-LPTS-TT1RMPWL2-RH LARGE $285.00 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 ROVI add $0.00 LPTS-TT1-PW4 ADJUSTER-DER REV1018 AVID REHAB add $0.00 LPTS-TT1-PW5 ADJUSTER 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 RECOMMENDED CUSHION NO MEDIAL *5.0 2.5-5.0 1 MEDIAL *4.0 2.25-4.0 *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 $103.00 BL-LPTS-GT2FXS-LH BL-LPTS-GT2FXS-LH BL-LPTS-GT2FXS-RH BL-LPTS-GT2FXS-RH E1028 $226.00 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 ADJUSTER-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 ADJUSTER DER FM Patient Reference: SUBMIT BY EMAIL PAGE 6 of 6 *DO NOT SEND PATIENT PROTECTED HEALTH INFMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*