COMFORT-TEK HY-GF-1620 HY-GF-1720 HY-GF-1820 HY-GF-1920 HY-GF-2020 HY-GF-2120 HY-GF-2220 HY-GF-2320 HY-GF-2420

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HYAITE ER FM HCPCS COING: E2603/E2604 SKIN PROTECTION SEAT Hyalite Company Name/ACCT #: P.O. Number: Requested By: Phone: Email: Ship To: Patient Reference: Fax: 1 SIZE & COVER 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. *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. $245.00 $367.00 $319.00 $478.00 20 HY-GF-1620 HY-GF-1720 HY-GF-1820 HY-GF-1920 HY-GF-2020 HY-GF-2120 HY-GF-2220 HY-GF-2320 HY-GF-2420 EPTH 19 18 17 16 HY-GF-1619 HY-GF-1719 HY-GF-1819 HY-GF-1919 HY-GF-2019 HY-GF-2119 HY-GF-2219 HY-GF-2319 HY-GF-2419 HY-GF-1618 HY-GF-1718 HY-GF-1818 HY-GF-1918 HY-GF-2018 HY-GF-2118 HY-GF-2218 HY-GF-2318 HY-GF-2418 HY-GF-1617 HY-GF-1717 HY-GF-1817 HY-GF-1917 HY-GF-2017 HY-GF-2117 HY-GF-2217 HY-GF-2317 HY-GF-2417 HY-GF-1616 HY-GF-1716 HY-GF-1816 HY-GF-1916 HY-GF-2016 HY-GF-2116 HY-GF-2216 HY-GF-2316 HY-GF-2416 16 17 18 19 20 21 22 23 24 WITH $245.00 $367.00 $319.00 $478.00 20 HY-GU-1620 HY-GU-1720 HY-GU-1820 HY-GU-1920 HY-GU-2020 HY-GU-2120 HY-GU-2220 HY-GU-2320 HY-GU-2420 EPTH 19 18 17 16 HY-GU-1619 HY-GU-1719 HY-GU-1819 HY-GU-1919 HY-GU-2019 HY-GU-2119 HY-GU-2219 HY-GU-2319 HY-GU-2419 HY-GU-1618 HY-GU-1718 HY-GU-1818 HY-GU-1918 HY-GU-2018 HY-GU-2118 HY-GU-2218 HY-GU-2318 HY-GU-2418 HY-GU-1617 HY-GU-1717 HY-GU-1817 HY-GU-1917 HY-GU-2017 HY-GU-2117 HY-GU-2217 HY-GU-2317 HY-GU-2417 HY-GU-1616 HY-GU-1716 HY-GU-1816 HY-GU-1916 HY-GU-2016 HY-GU-2116 HY-GU-2216 HY-GU-2316 HY-GU-2416 16 17 18 19 20 21 22 23 24 WITH HYAITE-ER REV1018 HYAITE 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 HYAITE ACCESSIES *All accessories are cosmetic changes to the cushion except for options in gray, which are add on items. 2.1 GROWTH NOTCHES MSRP $0.00 2.2 RAI CUTS MSRP $26.00 2.3 CO - COMES STANAR SIVER REFECTIVE PIPING MSRP $26.00 If growth notches are selected, a 1¼ wide cut will be taken from each side to allow the cushion to fit between the chair canes. EPTH OF NOTCHES 1¼ C A standard 1 1/2 wide cut will be made and you decide how high the cut will need to be. All cuts run the entire depth of the cushion. Accent colors can be applied to the cushion via colored piping. If no colors are selected, our standard silver reflective piping is used. TOP VIEW 1½ FRONT B CO OCATION C = 1 (GROWTH-NOTCH-1) B = 1 Rail Cut (RAI-CUT-1.0) Red (RE) Blue (BUE) C = 2 (GROWTH-NOTCH-2) B = 1½ Rail Cut (RAI-CUT-1.5) Purple (PURPE) Green (GREEN) C = 3 (GROWTH-NOTCH-3) B = 2 Rail Cut (RAI-CUT-2.0) Pink (PINK) Remove (REMOVE) C =Other (GROWTH-NOTCH-OTHER) Orange (ANGE) 2.4 KWIK STRAP MSRP $16.00 2.5 INCONTINENCE INER MSRP One = $60.00 - Two = $120.00 2.6 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. iner provides extra incontinence protection for the cushion. Rear View Kwik Strap (KWIK-STRAP) One Extra Incontinence iner (INCON-INER) Two Extra Incontinence iners (INCON-INER) 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) 2.7 REMOVABE SOI SEAT PAN & HARWARE KIT HCPCS Code: E2231 MSRP $387.00 2.8 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. 3/16 Plastic rigidizing board. HYAITE-ER REV1018 Solid Seat Pan & Hardware Kit (RSSP-N-HAR) Rigid Insert Glued (RG-INSERT-GUE) Rigid Insert Not Glued (RG-INSERT-UNGUE) HYAITE 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 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. 1.800.564.9248. 3.1 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 16 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 16 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. F SKIN PROTECTION & SHEAR REUCTION. NOT FUI RESISTANT. HYAITE-ER REV1018 COVER OPTIONS MSRP EFT *EXTRA EFT RIGHT *EXTRA RIGHT $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 HYAITE 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.*

3.5 A. BOIINK ATERA PEVIC/ THIGH SUPPT HARWARE TT HARWARE, SOT MOUNT TT HARWARE SOT MOUNT- FIXE TT HARWARE SOT MOUNT- REMOVABE 2.0-3.0 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. 3.0-4.5 4.0-6.5 SMA MEIUM ARGE HARWARE SIZE CEARANCE RECOMMENE SMA 3.0 2.0-3.0 MEIUM 4.5 3.0-4.5 ARGE 6.5 4.0-6.5 SIZE MSRP EFT EXTRA EFT RIGHT EXTRA RIGHT SMA $141.00 B-PTS-TT1FXS1-H B-PTS-TT1FXS1-H B-PTS-TT1FXS1-RH B-PTS-TT1FXS1-RH FIXE MEIUM $141.00 B-PTS-TT1FXS2-H B-PTS-TT1FXS2-H B-PTS-TT1FXS2-RH B-PTS-TT1FXS2-RH ARGE $141.00 B-PTS-TT1FXS3-H B-PTS-TT1FXS3-H B-PTS-TT1FXS3-RH B-PTS-TT1FXS3-RH REMOVABE SMA $248.00 B-PTS-TT1RMS1-H B-PTS-TT1RMS1-H B-PTS-TT1RMS1-RH B-PTS-TT1RMS1-RH MEIUM $248.00 B-PTS-TT1RMS2-H B-PTS-TT1RMS2-H B-PTS-TT1RMS2-RH B-PTS-TT1RMS2-RH ARGE $248.00 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 2.0-3.5 3.0-5.5 4.0-7.5 HARWARE SIZE CEARANCE RECOMMENE SMA 3.5 2.0-3.5 MEIUM 5.5 3.0-5.5 ARGE 7.5 4.0-7.5 SMA MEIUM ARGE SIZE MSRP EFT EXTRA EFT RIGHT EXTRA RIGHT SMA $185.00 B-PTS-TT1FXPW1-H B-PTS-TT1FXPW1-H B-PTS-TT1FXPW1-RH B-PTS-TT1FXPW1-RH FIXE MEIUM $185.00 B-PTS-TT1FXPW2-H B-PTS-TT1FXPW2-H B-PTS-TT1FXPW2-RH B-PTS-TT1FXPW2-RH ARGE $185.00 B-PTS-TT1FXPW3-H B-PTS-TT1FXPW3-H B-PTS-TT1FXPW3-RH B-PTS-TT1FXPW3-RH REMOVABE SMA $285.00 B-PTS-TT1RMPW1-H B-PTS-TT1RMPW1-H B-PTS-TT1RMPW1-RH B-PTS-TT1RMPW1-RH MEIUM $285.00 B-PTS-TT1RMPW2-H B-PTS-TT1RMPW2-H B-PTS-TT1RMPW2-RH B-PTS-TT1RMPW2-RH ARGE $285.00 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 HYAITE-ER REV1018 ROVI add $0.00 PTS-TT1-PW4 AVI REHAB add $0.00 PTS-TT1-PW5 HYAITE 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.*

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 *5.0 2.5-5.0 1 MEIA *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 EFT EXTRA EFT RIGHT EXTRA RIGHT FIXE $103.00 B-PTS-GT2FXS-H B-PTS-GT2FXS-H B-PTS-GT2FXS-RH B-PTS-GT2FXS-RH REMOVABE $226.00 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 HYAITE-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 HYAITE 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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