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SIZE & STYLE1

ADJUSTER® LOW & ADJUSTER® ORDER FORMHCPCS CODING: E2622/E2623ADJUSTABLE SKIN PROTECTION

Company Name/ACCT #:

P.O. Number:

Requested By:

Phone: Fax:

Email:

Ship To:

Patient Reference:

Adjuster®Adjuster® Low

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ADJUSTER® & ADJUSTER® LOW ORDER FORM Patient Reference: PAGE 1 of 5

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.

ADJUSTER® LOWPlease select size in the appropriate fabric chart below. Standard Adjuster® found on page 2.

$441.00 $441.00

DE

PTH

DE

PTH

WIDTH WIDTH

16” 16”

18” 18”19” 19”20” 20”16” 16”17” 17”

20” 20”

19” 19”

18” 18”

17” 17”

COMFORT-TEK™ STRETCH-AIR™

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





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


QUESTIONS? PLEASE CONTACT CUSTOMER SERVICE FOR ASSISTANCE. | 800.564.9248

SELECTED FOR AIR TRANSMISSION & HEAT DISSIPATION.

STRETCH-AIR™ SELECTED FOR INCONTINENCE PROTECTION

& AN EASILY CLEANED SURFACE.

COMFORT-TEK™OR

$441.00

$441.00

$488.00

$488.00

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PTH

DE

PTH

WIDTH

WIDTH

14”

14”

15”

15”

16”

16”

18”

18”

10”

10”

11”

11”

22”

22”

19”

19”

12”

12”

13”

13”

23”

23”

20”

20”

14”

14”

15”

15”

24”

24”

21”

21”

16”

16”

17”

17”

20”

20”

13”

13”

19”

19”

12”

12”

18”

18”

11”

11”

10”

10”

17”

17”

STRETCH-AIR™

COMFORT-TEK™

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-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




ADJUSTER®

Please select size in the appropriate fabric chart below.

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

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ADJUSTER® ACCESSORIES

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

2.5REMOVABLE SOLID SEAT PAN & HARDWARE KITHCPCS Code: E2231 MSRP $375.00

Rigid Insert Not Glued(RGD-INSERT-UNGLUED)

2.6RIGID 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. 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)

2.2KWIK STRAP®

MSRP $15.00

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

EXTRA VICAIR® AIR CELLSMSRP $41.00 / 50 air cell pack

Pack of 50 Vicair® Air Cells (AIRCELL50)

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)

2.1 INCONTINENCE LINERMSRP One = $58.00 - Two = $116.00

EXTRA COVERMSRP One = $60.00 - Two = $120.00

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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 $50.00

*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® $12.44/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 $136.82 BL-LPTS-TT1FXSL1-LH BL-LPTS-TT1FXSL1-LH BL-LPTS-TT1FXSL1-RH BL-LPTS-TT1FXSL1-RH

MEDIUM $136.82 BL-LPTS-TT1FXSL2-LH BL-LPTS-TT1FXSL2-LH BL-LPTS-TT1FXSL2-RH BL-LPTS-TT1FXSL2-RH

LARGE $136.82 BL-LPTS-TT1FXSL3-LH BL-LPTS-TT1FXSL3-LH BL-LPTS-TT1FXSL3-RH BL-LPTS-TT1FXSL3-RH

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SMALL $240.00 BL-LPTS-TT1RMSL1-LH BL-LPTS-TT1RMSL1-LH BL-LPTS-TT1RMSL1-RH BL-LPTS-TT1RMSL1-RH

MEDIUM $240.00 BL-LPTS-TT1RMSL2-LH BL-LPTS-TT1RMSL2-LH BL-LPTS-TT1RMSL2-RH BL-LPTS-TT1RMSL2-RH

LARGE $240.00 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 $179.00 BL-LPTS-TT1FXPWL1-LH BL-LPTS-TT1FXPWL1-LH BL-LPTS-TT1FXPWL1-RH BL-LPTS-TT1FXPWL1-RH

MEDIUM $179.00 BL-LPTS-TT1FXPWL2-LH BL-LPTS-TT1FXPWL2-LH BL-LPTS-TT1FXPWL2-RH BL-LPTS-TT1FXPWL2-RH

LARGE $179.00 BL-LPTS-TT1FXPWL3-LH BL-LPTS-TT1FXPWL3-LH BL-LPTS-TT1FXPWL3-RH BL-LPTS-TT1FXPWL3-RH

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SMALL $276.00 BL-LPTS-TT1RMPWL1-LH BL-LPTS-TT1RMPWL1-LH BL-LPTS-TT1RMPWL1-RH BL-LPTS-TT1RMPWL1-RH

MEDIUM $276.00 BL-LPTS-TT1RMPWL2-LH BL-LPTS-TT1RMPWL2-LH BL-LPTS-TT1RMPWL2-RH BL-LPTS-TT1RMPWL2-RH

LARGE $276.00 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 $100.00 BL-LPTS-GT2FXS-LH BL-LPTS-GT2FXS-LH BL-LPTS-GT2FXS-RH BL-LPTS-GT2FXS-RH

REMOVABLEE1028

$219.40 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 $35.00/arm BL-LPTS-TT1LARM4 BL-LPTS-TT1LARM4 BL-LPTS-TT1LARM4 BL-LPTS-TT1LARM4

GT ADDITIONAL HARDWARE LINKS

LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT

MSRP $35.00/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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