1.1 ADJUSTER LOWHCPCS Code: E2622/E2623

SIZE & COVER1

ORDER FORM 1 of 3

ADJUSTER LOW ORDER FORMHCPCS CODING: E2622/E2623ADJUSTABLE SKIN PROTECTION

STRETCH AIR STANDARD SIZES

SEA

T D

EP

TH

FRAME WIDTH

AJ-SL-1620 AJ-SL-1820 AJ-SL-2020

AJ-SL-1618 AJ-SL-1818 AJ-SL-2018

AJ-SL-1616 AJ-SL-1816 AJ-SL-201616”

18”

20”

16” 18” 20”

$44100

OR

COMFORT TEKSELECTED FOR INCONTINENCE

PROTECTION & AN EASILY CLEANED

SURFACE.

STRETCH AIRSELECTED FOR AIR TRANSMISSION &

HEAT DISSIPATION. PROVIDES NO

INCONTINENCE PROTECTION.

Company Name/ACCT #:

P.O. Number:

Requested By:

Phone: Fax:

Email:

Ship To:

Patient Reference:

Patient Reference:ADJUSTER LOW ORDER FORM

COMFORT TEK STANDARD SIZES

SEA

T D

EP

TH

FRAME WIDTH

AJ-FL-1620 AJ-FL-1820 AJ-FL-2020

AJ-FL-1618 AJ-FL-1818 AJ-FL-2018

AJ-FL-1616 AJ-FL-1816 AJ-FL-201616”

18”

20”

16” 18” 20”

$44100

CHOOSE SIZE IN APPROPRIATE FABRIC CHART

Odd sizes may be available and are subject to upcharge. Please contact customer service for details.

VICAIR® ACCESSORIES (OPTIONAL)2

Solid Seat Pan & Hardware Kit(RSSP-N-HARD)

2.4REMOVABLE SOLID SEAT PAN & HARDWARE KITHCPCS Code: E2231 MSRP $375.00

Rigid Insert Not Glued(RGD-INSERT-UNGLUED)

2.5RIGID INSERTHCPCS Code: E0992 MSRP $63.00

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. Hip guides can be easily attached.

3/16” Plastic rigidizing board.

2.2 INCONTINENCE LINERMSRP $58.00/ea

Incontinence Liner provides extra incontinence protection for the cushion.

One Extra Incontinence Liner (INCON-LINER)

Two Extra Incontinence Liners (INCON-LINER)

2.3 EXTRA COVERMSRP $60.00/ea

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)

Two Extra Comfort Tek Outer Cover (2X-COMFORT-TEK-CV)

Kwik Strap®

(KWIK-STRAP)

2.1 KWIK STRAP®

MSRP $15.00

Kwik Strap® provides extra security. Kwik Strap® is Velcroed to the bottom of the cushion and loops around vertical canes to securely attach cushion to wheelchair during transfers.

Rear View

*All accessories are cosmetic changes to the cushion except for options in gray, which are add on items.

2.6EXTRA VICAIR® AIR CELLS50 air cell packMSRP $41.00

Pack of 50 Vicair® Air Cells (AIRCELL50)

2.7 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)

ORDER FORM 2 of 3Patient Reference:ADJUSTER LOW ORDER FORM

ORDER FORM 3 of 3Patient Reference:ADJUSTER LOW ORDER FORM

COMFORT TEKSELECTED FOR INCONTINENCE

PROTECTION & AN EASILY CLEANED

SURFACE.

STRETCH AIRSELECTED FOR AIR TRANSMISSION &

HEAT DISSIPATION. PROVIDES NO

INCONTINENCE PROTECTION.

3.1LATERAL THIGH SUPPORTSHCPCS Code: E0956 (OPTIONAL)

3.2

NON-REMOVABLE HARDWAREMSRP $100.00/ea

LEFT (HGL-RS) RIGHT (HGR-RS)

(1) EXTRA L (1) EXTRA R

(2) EXTRA L (2) EXTRA R

5”

5”

STRETCH AIRFABRIC

Extra L L SIZE R Extra R

(HG1-RS3H4D) 3” H x 4” D (HG1-

RS3H4D)

(HG1-RS3H5D) 3” H x 5” D (HG1-

RS3H5D)

(HG1-RS4H4D) 4” H x 4” D (HG1-

RS4H4D)

(HG1-RS4H6D) 4” H x 6” D (HG1-

RS4H6D)

(HG1-RS4H8D) 4” H x 8” D (HG1-

RS4H8D)

(HG1-RS4H10D) 4” H x 10” D (HG1-

RS4H10D)

(HG1-RS4H12D) 4” H x 12” D (HG1-

RS4H12D)

(HG1-RS4H14D) 4” H x 14” D (HG1-

RS4H14D)

(HG1-RS4H16D) 4” H x 16” D (HG1-

RS4H16D)

H D H D

LATERAL THIGH SUPPORTS3

STRETCH AIRFABRIC

Extra L L SIZE R Extra R

(HG1-RS3H4D-AL) 3” H x 4” D (HG1-

RS3H4D-AR)

(HG1-RS3H5D-AL) 3” H x 5” D (HG1-

RS3H5D-AR)

(HG1-RS4H4D-AL) 4” H x 4” D (HG1-

RS4H4D-AR)

(HG1-RS4H6D-AL) 4” H x 6” D (HG1-

RS4H6D-AR)

(HG1-RS4H8D-AL) 4” H x 8” D (HG1-

RS4H8D-AR)

(HG1-RS4H10D-AL) 4” H x 10” D (HG1-

RS4H10D-AR)

(HG1-RS4H12D-AL) 4” H x 12” D (HG1-

RS4H12D-AR)

(HG1-RS4H14D-AL) 4” H x 14” D (HG1-

RS4H14D-AR)

(HG1-RS4H16D-AL) 4” H x 16” D (HG1-

RS4H16D-AR)

COMFORT TEKFABRIC

Extra L L SIZE R Extra R

(HG1-RF3H4D) 3” H x 4” D (HG1-

RF3H4D)

(HG1-RF3H5D) 3” H x 5” D (HG1-

RF3H5D)

(HG1-RF4H4D) 4” H x 4” D (HG1-

RF4H4D)

(HG1-RF4H6D) 4” H x 6” D (HG1-

RF4H6D)

(HG1-RF4H8D) 4” H x 8” D (HG1-

RF4H8D)

(HG1-RF4H10D) 4” H x 10” D (HG1-

RF4H10D)

(HG1-RF4H12D) 4” H x 12” D (HG1-

RF4H12D)

(HG1-RF4H14D) 4” H x 14” D (HG1-

RF4H14D)

(HG1-F4H16D) 4” H x 16” D (HG1-

RF4H16D)

COMFORT TEKFABRIC

Extra L L SIZE R Extra R

(HG1-RF3H4D-AL) 3” H x 4” D (HG1-

R3H4D-AR)

(HG1-RF3H5D-AL) 3” H x 5” D (HG1-

R3H5D-AR)

(HG1-RF4H4D-AL) 4” H x 4” D (HG1-

R4H4D-AR)

(HG1-RF4H6D-AL) 4” H x 6” D (HG1-

R4H6D-AR)

(HG1-RF4H8D-AL) 4” H x 8” D (HG1-

R4H8D-AR)

(HG1-R4H10D-AL) 4” H x 10” D (HG1-

R4H10D-AR)

(HG1-R4H12D-AL) 4” H x 12” D (HG1-

R4H12D-AR)

(HG1-R4H14D-AL) 4” H x 14” D (HG1-

R4H14D-AR)

(HG1-R4H16D-AL) 4” H x 16” D (HG1-

R4H16D-AR)

- OR - - OR -

ADDITIONAL LINKMSRP $35.00/extra link

LEFT (HG1-LINK) RIGHT (HG1-LINK)

(1) EXTRA L (1) EXTRA R

(2) EXTRA L (2) EXTRA R

(3) EXTRA L (3) EXTRA R

B.

1”

Select a left and/or right Lateral Thigh Support using ANY combination of size, style and fabric.

Contact Customer Service for custom sizes that are not listed below. 1.800.564.9248.

T-Nut spacing along hip support is 1” on center running the entire length of the pad.

QUICK-RELEASE HARDWARE MSRP $240.00/ea

LEFT (HGL-QR) RIGHT (HGR-QR)

(1) EXTRA L (1) EXTRA R

(2) EXTRA L (2) EXTRA R

A.

Lateral thigh support hardware will allow for width adjustability. Brackets come standard with 2 links in Section A. Each extra link provides 1” of height. Additional links are available for more adjustability in Section B.

- OR -

ANGLE ADJUSTABLE REMOVABLE ANGLE

ADJUSTABLE

SEE DETAIL A

SEE DETAIL B

SEE DETAIL A

SEE DETAIL B

SEE DETAIL A

SEE DETAIL B5”

5”

STANDARD RIGIDMSRP $50.00/ea

LATERAL THIGH SUPPORT HARDWAREHCPCS Code: E0956

CONTOURED RIGIDMSRP $50.00/ea