LIBERTY X ORDER FORM - d37xlajmpyyml6.cloudfront.netd37xlajmpyyml6.cloudfront.net/standard_order_forms/Liberty X Order... · liberty-x-order rev0418 liberty® x order form patient

$477.00

$515.00

$477.00

$515.00

SIZE & STYLE1

LIBERTY® X ORDER FORMHCPCS CODING: E2622ADJUSTABLE SKIN PROTECTION

Company Name/ACCT #:

P.O. Number:

Requested By:

Phone: Fax:

Email:

Ship To:

Patient Reference:

Liberty® X shown with GlideWear® Liberty® X Liner and Foam Base

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WIDTH

WIDTH

WIDTH

WIDTH

LBX-F-1820 LBX-F-2020

LBX-F-1618 LBX-F-1818 LBX-F-2018

LBX-F-1717

LBX-F-1616 LBX-F-1816

LBX-FQ-1820 LBX-FQ-2020

LBX-FQ-1618 LBX-FQ-1818 LBX-FQ-2018

LBX-FQ-1717

LBX-FQ-1616 LBX-FQ-1816

LBX-S-1820 LBX-S-2020

LBX-S-1618 LBX-S-1818 LBX-S-2018

LBX-S-1717

LBX-S-1616 LBX-S-1816

LBX-SQ-1820 LBX-SQ-2020

LBX-SQ-1618 LBX-SQ-1818 LBX-SQ-2018

LBX-SQ-1717

LBX-SQ-1616 LBX-SQ-1816

16”

16”

16”

16”

18”

18”

18”

18”

19”

19”

19”

19”

20”

20”

20”

20”

16”

16”

16”

16”

17”

17”

17”

17”

20”

20”

20”

20”

19”

19”

19”

19”

18”

18”

18”

18”

17”

17”

17”

17”

COMFORT-TEK™

COMFORT-TEK™ with GLIDEWEAR®

STRETCH-AIR™

STRETCH-AIR™ with GLIDEWEAR®

LIBERTY® X ORDER FORM Patient Reference: PAGE 1 of 4

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 Service at [email protected] or 1.406.522.8563.

Please select size in the appropriate fabric chart below.

LIBERTY® X with

GLIDEWEAR® 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. GLIDEWEAR® Patent No. 8,646,459

SELECTED FOR AIR TRANSMISSION & HEAT DISSIPATION.

STRETCH-AIR™ SELECTED FOR INCONTINENCE PROTECTION

& AN EASILY CLEANED SURFACE.

COMFORT-TEK™OR

QUESTIONS? PLEASE CONTACT CUSTOMER SERVICE FOR ASSISTANCE. | 800.564.9248

Liberty® X is not recommended for use in altitudes above 3,000 ft.

Red (RED) Silver Reflective (SILVER)

Purple (PURPLE) Green (GREEN)

Pink (PINK) Remove (REMOVE)

Orange (ORANGE)


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

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LIBERTY® X ACCESSORIES

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

2.5REMOVABLE SOLID SEAT PAN & HARDWARE KITHCPCS Code: E2231 MSRP $387.00

Rigid Insert Not Glued(RGD-INSERT-UNGLUED)

2.6 RIGID INSERTHCPCS 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. Lateral thigh support hardware can be easily attached.

3/16” Plastic rigidizing board.

2.3

Liner provides extra incontinence protection for the cushion.

One Extra Incontinence Liner (INCON-LINER)

Two Extra Incontinence Liners (INCON-LINER)

2.4

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)

2.2 KWIK STRAP®

MSRP $16.00

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.

Rear View

2.7 VICAIR® PELVIC STABILIZER MSRP $118.00

(fits) 16W x 16D -OR- 16W x 18D (PS-1618)

(fits) 18W x 16D -OR- 18W x 18D (PS-1818)

2.1COLOR - COMES STANDARD W/ REFLECTIVE BLUE PIPINGMSRP $26.00

Accent colors can be applied to the cushion via colored piping. If no colors are selected, our standard reflective blue piping is used.

COLOR LOCATION

INCONTINENCE LINERMSRP One = $60.00 - Two = $120.00

EXTRA COVERMSRP One = $62.00 - Two = $124.00

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BODILINK® LATERAL PELVIC/THIGH SUPPORT HARDWARE & PADS3

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3”L x 4”D BL-LPTSP1A-3L4D-LH BL-LPTSP1A-3L4D-LH BL-LPTSP1A-3L4D-RH BL-LPTSP1A-3L4D-RH










STYLE SIZE LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT

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3”L x 4”D BL-LPTSP1Z-3L4D-LH BL-LPTSP1Z-3L4D-LH BL-LPTSP1Z-3L4D-RH BL-LPTSP1Z-3L4D-RH






4”L x 12” D BL-LPTSP1Z-4L12D-LH BL-LPTSP1Z-4L12D-LH BL-LPTSP1Z-4L12D-RH BL-LPTSP1Z-4L12D-RH




LD

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.

OR

3.1BASIC PAD SIZE & SHAPEHCPCS Code: E0953 MSRP $52.00

*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.

• You may make one selection per column (Left, Extra Left, Right, and Extra Right) in section 3.1.• Follow each column down to section 3.2 and select a style and cover for each pad selected in section 3.1.

COVER OPTIONS MSRP LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT

COMFORT-TEK™ $0.00/ea. LPTS-P1-COMFORT LPTS-P1-COMFORT LPTS-P1-COMFORT LPTS-P1-COMFORT

STRETCH-AIR™ $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

FOR SKIN PROTECTION & SHEAR REDUCTION. NOT FLUID RESISTANT.

STRETCH-AIR™FOR AIR TRANSMISSION

& HEAT DISSIPATION.

COMFORT-TEK™FOR FLUID PROTECTION & AN

EASILY CLEANED SURFACE.

3.2 BASIC PAD COVER

3.3

TT HARDWARE, SLOT MOUNT

A.

BODILINK® LATERAL PELVIC/THIGH SUPPORT HARDWARE

SIZE MSRP LEFT *EXTRA LEFT RIGHT * EXTRA RIGHT

FIX

ED

SMALL $141.00 BL-LPTS-TT1FXSL1-LH BL-LPTS-TT1FXSL1-LH BL-LPTS-TT1FXSL1-RH BL-LPTS-TT1FXSL1-RH

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

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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

OR

HARDWARE SIZEMAX CUSHION

THICKNESS CLEARANCE

RECOMMENDED CUSHION

THICKNESS

SMALL 3.0” 2.0”- 3.0”

MEDIUM 4.5” 3.0”- 4.5”

LARGE 6.5” 4.0”- 6.5”

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SMALL MEDIUM LARGE

HARDWARE SIZE V. CUSHION THICKNESS

2.0”- 3.0”

3.0”- 4.5”

4.0”- 6.5”

• You may make one selection per column (Left, Extra Left, Right, and Extra Right) in section 3.3 from group A, B, -OR- C.

• TT long extention arms (section 3.4) will only work with TT style hardware. • GT hardware extra links (section 3.4) will only work with GT style hardware.

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SMALL MEDIUM LARGE

HARDWARE SIZE V. CUSHION THICKNESS

2.0”- 3.5”

3.0”- 5.5”

4.0”- 7.5”TT HARDWARE, POWER MOUNT B.

HARDWARE SIZEMAX CUSHION

THICKNESS CLEARANCE

RECOMMENDED CUSHION

THICKNESS

SMALL 3.5” 2.0”- 3.5”

MEDIUM 5.5” 3.0”- 5.5”

LARGE 7.5” 4.0”- 7.5”

SIZE MSRP LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT

FIX

ED

SMALL $185.00 BL-LPTS-TT1FXPWL1-LH BL-LPTS-TT1FXPWL1-LH BL-LPTS-TT1FXPWL1-RH BL-LPTS-TT1FXPWL1-RH

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

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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

OR

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

AVID REHAB add $0.00 LPTS-TT1-PW5

TT HARDWARE, POWER MOUNT OPTION

GT HARDWARE (ONLY SLOT MOUNT)

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

REMOVABLEE1028

$226.00 BL-LPTS-GT2RMS-LH BL-LPTS-GT2RMS-LH BL-LPTS-GT2RMS-RH BL-LPTS-GT2RMS-RH

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HARDWAREMAX CUSHION

THICKNESS CLEARANCE

RECOMMENDED CUSHION

THICKNESS

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.

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3.4 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

LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT

MSRP $37.00/link(2 Additional 1.25” Links Allowed

Per Hardware Ordered)

BL-LPTS-GT2LINK BL-LPTS-GT2LINK BL-LPTS-GT2LINK BL-LPTS-GT2LINK

BL-LPTS-GT2LINK BL-LPTS-GT2LINK BL-LPTS-GT2LINK BL-LPTS-GT2LINK

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Documents

LIBERTY X ORDER FORM - d37xlajmpyyml6.cloudfront.netd37xlajmpyyml6.cloudfront.net/standard_order_forms/Liberty X Order... · liberty-x-order rev0418 liberty® x order form patient