ADJUSTER LOW & ADJUSTER ORDER FORM
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1 ADJUSTER LOW & ADJUSTER DER FM HCPCS CODING: E2622/E2623 ADJUSTABLE SKIN PROTECTION Company Name/ACCT #: P.O. Number: Adjuster Low Adjuster Requested By: Phone: Fax: Ship To: Patient Reference: 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 or print and fax to Customer Service at customerservice@comfortcompany.com or SELECTED F INCONTINENCE PROTECTION & AN EASILY CLEANED SURFACE. SELECTED F AIR TRANSMISSION ADJUSTER LOW Please select size in the appropriate fabric chart below. Standard Adjuster found on page 2. $ $ 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 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 ADJUSTER & ADJUSTER LOW DER FM Patient Reference: PAGE 1 of 5
2 SELECTED F INCONTINENCE PROTECTION & AN EASILY CLEANED SURFACE. SELECTED F AIR TRANSMISSION ADJUSTER Please select size in the appropriate fabric chart below. DEPTH DEPTH $ $ 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 $ $ 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 QUESTIONS? PLEASE CONTACT CUSTOMER SERVICE F ASSISTANCE ADJUSTER & ADJUSTER LOW DER FM Patient Reference: PAGE 2 of 5
3 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 = $ Two = $ EXTRA COVER MSRP One = $ Two = $ 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 $ RIGID INSERT HCPCS Code: E0992 MSRP $ 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 $ (fits) 16W x 16D -- 16W x 18D (PS-1618) (fits) 18W x 16D -- 18W x 18D (PS-1818) ADJUSTER & ADJUSTER LOW DER FM Patient Reference: PAGE 3 of 5
4 3.1 3 BODILINK LATERAL PELVIC/THIGH SUPPT HARDWARE & PADS BASIC PAD SIZE & SHAPE HCPCS Code: E0953 MSRP $52.00 Please select sizes in the appropriate fabric & style charts below. Contact Customer Support for custom sizes that are not listed below 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. *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 D BL-LPTSP1Z-4L10D-LH BL-LPTSP1Z-4L10D-LH BL-LPTSP1Z-4L10D-RH BL-LPTSP1Z-4L10D-RH 4 L x D BL-LPTSP1Z-4L12D-LH BL-LPTSP1Z-4L12D-LH BL-LPTSP1Z-4L12D-RH BL-LPTSP1Z-4L12D-RH 4 L x 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 D BL-LPTSP1A-4L10D-LH BL-LPTSP1A-4L10D-LH BL-LPTSP1A-4L10D-RH BL-LPTSP1A-4L10D-RH 4 L x D BL-LPTSP1A-4L12D-LH BL-LPTSP1A-4L12D-LH BL-LPTSP1A-4L12D-RH BL-LPTSP1A-4L12D-RH 4 L x 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 3.2 BASIC PAD COVER F FLUID PROTECTION & AN EASILY CLEANED SURFACE. F AIR TRANSMISSION F SKIN PROTECTION & SHEAR REDUCTION. NOT FLUID RESISTANT. COVER OPTIONS MSRP LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT $0.00/ea. LPTS-P1-COMFT LPTS-P1-COMFT LPTS-P1-COMFT LPTS-P1-COMFT $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 3.3 A. BODILINK LATERAL PELVIC/ THIGH SUPPT HARDWARE, SLOT MOUNT SLOT MOUNT- FIXED SLOT MOUNT You may make one selection per column (Left, Extra Left, Right, and Extra Right) in section 3.3 from group A, B, -- 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. V SMALL MEDIUM LARGE SMALL MEDIUM LARGE SIZE MSRP LEFT *EXTRA LEFT RIGHT * EXTRA RIGHT SMALL $ BL-LPTS-TT1FXSL1-LH BL-LPTS-TT1FXSL1-LH BL-LPTS-TT1FXSL1-RH BL-LPTS-TT1FXSL1-RH FIXED MEDIUM $ BL-LPTS-TT1FXSL2-LH BL-LPTS-TT1FXSL2-LH BL-LPTS-TT1FXSL2-RH BL-LPTS-TT1FXSL2-RH LARGE $ BL-LPTS-TT1FXSL3-LH BL-LPTS-TT1FXSL3-LH BL-LPTS-TT1FXSL3-RH BL-LPTS-TT1FXSL3-RH SMALL $ BL-LPTS-TT1RMSL1-LH BL-LPTS-TT1RMSL1-LH BL-LPTS-TT1RMSL1-RH BL-LPTS-TT1RMSL1-RH MEDIUM $ BL-LPTS-TT1RMSL2-LH BL-LPTS-TT1RMSL2-LH BL-LPTS-TT1RMSL2-RH BL-LPTS-TT1RMSL2-RH LARGE $ BL-LPTS-TT1RMSL3-LH BL-LPTS-TT1RMSL3-LH BL-LPTS-TT1RMSL3-RH BL-LPTS-TT1RMSL3-RH ADJUSTER & ADJUSTER LOW DER FM Patient Reference: PAGE 4 of 5
5 B., POWER MOUNT V POWER MOUNT- FIXED POWER MOUNT SMALL MEDIUM LARGE SMALL MEDIUM LARGE SIZE MSRP LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT FIXED SMALL $ BL-LPTS-TT1FXPWL1-LH BL-LPTS-TT1FXPWL1-LH BL-LPTS-TT1FXPWL1-RH BL-LPTS-TT1FXPWL1-RH MEDIUM $ BL-LPTS-TT1FXPWL2-LH BL-LPTS-TT1FXPWL2-LH BL-LPTS-TT1FXPWL2-RH BL-LPTS-TT1FXPWL2-RH LARGE $ BL-LPTS-TT1FXPWL3-LH BL-LPTS-TT1FXPWL3-LH BL-LPTS-TT1FXPWL3-RH BL-LPTS-TT1FXPWL3-RH SMALL $ BL-LPTS-TT1RMPWL1-LH BL-LPTS-TT1RMPWL1-LH BL-LPTS-TT1RMPWL1-RH BL-LPTS-TT1RMPWL1-RH MEDIUM $ BL-LPTS-TT1RMPWL2-LH BL-LPTS-TT1RMPWL2-LH BL-LPTS-TT1RMPWL2-RH BL-LPTS-TT1RMPWL2-RH LARGE $ 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 AVID REHAB add $0.00 LPTS-TT1-PW5 C. GT HARDWARE (ONLY SLOT MOUNT) GT HARDWARE SLOT MOUNT- FIXED GT HARDWARE SLOT MOUNT- HARDWARE SIZE MSRP LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT FIXED $ BL-LPTS-GT2FXS-LH BL-LPTS-GT2FXS-LH BL-LPTS-GT2FXS-RH BL-LPTS-GT2FXS-RH $ BL-LPTS-GT2RMS-LH BL-LPTS-GT2RMS-LH BL-LPTS-GT2RMS-RH BL-LPTS-GT2RMS-RH NO MEDIAL 1 MEDIAL NO MEDIAL * MEDIAL * *If you need to increase the height or medial reach, add additional links in section 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 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 & ADJUSTER LOW DER FM Patient Reference: SUBMIT BY PAGE 5 of 5
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