M2 Zero Elevation COMFORT-TEK $402.00

Transcription

1 M2 DER FM HCPCS CODING: E2607/E2608 SKIN PROTECTION & POSITIONING SEAT CUSHION Company Name/ACCT #: P.O. Number: Requested By: M2 shown with GlideWear M2 Zero Elevation Phone: Fax: Ship To: Patient Reference: 1 SIZE & STYLE ZERO ELEVATION 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 & HEAT DISSIPATION. M2-F-1824 M2-F-1924 M2-F-2024 M2-F-2124 M2-F-2224 M2-F-2324 M2-F-2424 M2-F-1823 M2-F-1923 M2-F-2023 M2-F-2123 M2-F-2223 M2-F-2323 M2-F-2423 M2-F-1622 M2-F-1722 M2-F-1822 M2-F-1922 M2-F-2022 M2-F-2122 M2-F-2222 M2-F-2322 M2-F-2422 M2-F-1521 M2-F-1621 M2-F-1721 M2-F-1821 M2-F-1921 M2-F-2021 M2-F-2121 M2-F-2221 M2-F-2321 M2-F-2421 M2-F-1420 M2-F-1520 M2-F-1620 M2-F-1720 M2-F-1820 M2-F-1920 M2-F-2020 M2-F-2120 M2-F-2220 M2-F-2320 M2-F-2420 M2-F-1419 M2-F-1519 M2-F-1619 M2-F-1719 M2-F-1819 M2-F-1919 M2-F-2019 M2-F-2119 M2-F-2219 M2-F-2319 M2-F-2419 M2-F-1218 M2-F-1318 M2-F-1418 M2-F-1518 M2-F-1618 M2-F-1718 M2-F-1818 M2-F-1918 M2-F-2018 M2-F-2118 M2-F-2218 M2-F-2318 M2-F-2418 M2-F-1117 M2-F-1217 M2-F-1317 M2-F-1417 M2-F-1517 M2-F-1617 M2-F-1717 M2-F-1817 M2-F-1917 M2-F-2017 M2-F-2117 M2-F-2217 M2-F-2317 M2-F-2417 M2-F-1016 M2-F-1116 M2-F-1216 M2-F-1316 M2-F-1416 M2-F-1516 M2-F-1616 M2-F-1716 M2-F-1816 M2-F-1916 M2-F-2016 M2-F-2116 M2-F-2216 M2-F-2316 M2-F-2416 M2-F-1015 M2-F-1115 M2-F-1215 M2-F-1315 M2-F-1415 M2-F-1515 M2-F-1615 M2-F-1715 M2-F-1815 M2-F-1915 M2-F-2015 M2-F-1014 M2-F-1114 M2-F-1214 M2-F-1314 M2-F-1414 M2-F-1514 M2-F-1614 M2-F-1714 M2-F-1814 M2-F-1914 M2-F-1013 M2-F-1113 M2-F-1213 M2-F-1313 M2-F-1413 M2-F-1513 M2-F-1613 M2-F-1713 M2-F-1012 M2-F-1112 M2-F-1212 M2-F-1312 M2-F-1412 M2-F-1512 M2-F-1612 M2-F-1712 M2-F-1011 M2-F-1111 M2-F-1211 M2-F-1311 M2-F-1411 M2-F-1511 M2-F-1010 M2-F-1110 M2-F-1210 M2-F-1310 M2-F-1410 M2-F-1510 M2-S-1824 M2-S-1924 M2-S-2024 M2-S-2124 M2-S-2224 M2-S-2324 M2-S-2424 M2-S-1823 M2-S-1923 M2-S-2023 M2-S-2123 M2-S-2223 M2-S-2323 M2-S-2423 M2-S-1622 M2-S-1722 M2-S-1822 M2-S-1922 M2-S-2022 M2-S-2122 M2-S-2222 M2-S-2322 M2-S-2422 M2-S-1521 M2-S-1621 M2-S-1721 M2-S-1821 M2-S-1921 M2-S-2021 M2-S-2121 M2-S-2221 M2-S-2321 M2-S-2421 M2-S-1420 M2-S-1520 M2-S-1620 M2-S-1720 M2-S-1820 M2-S-1920 M2-S-2020 M2-S-2120 M2-S-2220 M2-S-2320 M2-S-2420 M2-S-1419 M2-S-1519 M2-S-1619 M2-S-1719 M2-S-1819 M2-S-1919 M2-S-2019 M2-S-2119 M2-S-2219 M2-S-2319 M2-S-2419 M2-S-1218 M2-S-1318 M2-S-1418 M2-S-1518 M2-S-1618 M2-S-1718 M2-S-1818 M2-S-1918 M2-S-2018 M2-S-2118 M2-S-2218 M2-S-2318 M2-S-2418 M2-S-1117 M2-S-1217 M2-S-1317 M2-S-1417 M2-S-1517 M2-S-1617 M2-S-1717 M2-S-1817 M2-S-1917 M2-S-2017 M2-S-2117 M2-S-2217 M2-S-2317 M2-S-2417 M2-S-1016 M2-S-1116 M2-S-1216 M2-S-1316 M2-S-1416 M2-S-1516 M2-S-1616 M2-S-1716 M2-S-1816 M2-S-1916 M2-S-2016 M2-S-2116 M2-S-2216 M2-S-2316 M2-S-2416 M2-S-1015 M2-S-1115 M2-S-1215 M2-S-1315 M2-S-1415 M2-S-1515 M2-S-1615 M2-S-1715 M2-S-1815 M2-S-1915 M2-S-2015 M2-S-1014 M2-S-1114 M2-S-1214 M2-S-1314 M2-S-1414 M2-S-1514 M2-S-1614 M2-S-1714 M2-S-1814 M2-S-1914 M2-S-1013 M2-S-1113 M2-S-1213 M2-S-1313 M2-S-1413 M2-S-1513 M2-S-1613 M2-S-1713 M2-S-1012 M2-S-1112 M2-S-1212 M2-S-1312 M2-S-1412 M2-S-1512 M2-S-1612 M2-S-1712 M2-S-1011 M2-S-1111 M2-S-1211 M2-S-1311 M2-S-1411 M2-S-1511 M2-S-1010 M2-S-1110 M2-S-1210 M2-S-1310 M2-S-1410 M2-S-1510 M2 DER FM Patient Reference: PAGE 1 of 9

2 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 ZERO ELEVATION with SELECTED F INCONTINENCE PROTECTION SELECTED F AIR TRANSMISSION with GLIDEWEAR M2-FQ-1824 M2-FQ-1924 M2-FQ-2024 M2-FQ-2124 M2-FQ-2224 M2-FQ-2324 M2-FQ-2424 M2-FQ-1823 M2-FQ-1923 M2-FQ-2023 M2-FQ-2123 M2-FQ-2223 M2-FQ-2323 M2-FQ-2423 M2-FQ-1622 M2-FQ-1722 M2-FQ-1822 M2-FQ-1922 M2-FQ-2022 M2-FQ-2122 M2-FQ-2222 M2-FQ-2322 M2-FQ-2422 M2-FQ-1521 M2-FQ-1621 M2-FQ-1721 M2-FQ-1821 M2-FQ-1921 M2-FQ-2021 M2-FQ-2121 M2-FQ-2221 M2-FQ-2321 M2-FQ-2421 M2-FQ-1420 M2-FQ-1520 M2-FQ-1620 M2-FQ-1720 M2-FQ-1820 M2-FQ-1920 M2-FQ-2020 M2-FQ-2120 M2-FQ-2220 M2-FQ-2320 M2-FQ-2420 M2-FQ-1419 M2-FQ-1519 M2-FQ-1619 M2-FQ-1719 M2-FQ-1819 M2-FQ-1919 M2-FQ-2019 M2-FQ-2119 M2-FQ-2219 M2-FQ-2319 M2-FQ-2419 M2-FQ-1218 M2-FQ-1318 M2-FQ-1418 M2-FQ-1518 M2-FQ-1618 M2-FQ-1718 M2-FQ-1818 M2-FQ-1918 M2-FQ-2018 M2-FQ-2118 M2-FQ-2218 M2-FQ-2318 M2-FQ-2418 M2-FQ-1117 M2-FQ-1217 M2-FQ-1317 M2-FQ-1417 M2-FQ-1517 M2-FQ-1617 M2-FQ-1717 M2-FQ-1817 M2-FQ-1917 M2-FQ-2017 M2-FQ-2117 M2-FQ-2217 M2-FQ-2317 M2-FQ-2417 M2-FQ-1016 M2-FQ-1116 M2-FQ-1216 M2-FQ-1316 M2-FQ-1416 M2-FQ-1516 M2-FQ-1616 M2-FQ-1716 M2-FQ-1816 M2-FQ-1916 M2-FQ-2016 M2-FQ-2116 M2-FQ-2216 M2-FQ-2316 M2-FQ-2416 M2-FQ-1015 M2-FQ-1115 M2-FQ-1215 M2-FQ-1315 M2-FQ-1415 M2-FQ-1515 M2-FQ-1615 M2-FQ-1715 M2-FQ-1815 M2-FQ-1915 M2-FQ-2015 M2-FQ-1014 M2-FQ-1114 M2-FQ-1214 M2-FQ-1314 M2-FQ-1414 M2-FQ-1514 M2-FQ-1614 M2-FQ-1714 M2-FQ-1814 M2-FQ-1914 M2-FQ-1013 M2-FQ-1113 M2-FQ-1213 M2-FQ-1313 M2-FQ-1413 M2-FQ-1513 M2-FQ-1613 M2-FQ-1713 M2-FQ-1012 M2-FQ-1112 M2-FQ-1212 M2-FQ-1312 M2-FQ-1412 M2-FQ-1512 M2-FQ-1612 M2-FQ-1712 M2-FQ-1011 M2-FQ-1111 M2-FQ-1211 M2-FQ-1311 M2-FQ-1411 M2-FQ-1511 M2-FQ-1010 M2-FQ-1110 M2-FQ-1210 M2-FQ-1310 M2-FQ-1410 M2-FQ-1510 with GLIDEWEAR M2-SQ-1824 M2-SQ-1924 M2-SQ-2024 M2-SQ-2124 M2-SQ-2224 M2-SQ-2324 M2-SQ-2424 M2-SQ-1823 M2-SQ-1923 M2-SQ-2023 M2-SQ-2123 M2-SQ-2223 M2-SQ-2323 M2-SQ-2423 M2-SQ-1622 M2-SQ-1722 M2-SQ-1822 M2-SQ-1922 M2-SQ-2022 M2-SQ-2122 M2-SQ-2222 M2-SQ-2322 M2-SQ-2422 M2-SQ-1521 M2-SQ-1621 M2-SQ-1721 M2-SQ-1821 M2-SQ-1921 M2-SQ-2021 M2-SQ-2121 M2-SQ-2221 M2-SQ-2321 M2-SQ-2421 M2-SQ-1420 M2-SQ-1520 M2-SQ-1620 M2-SQ-1720 M2-SQ-1820 M2-SQ-1920 M2-SQ-2020 M2-SQ-2120 M2-SQ-2220 M2-SQ-2320 M2-SQ-2420 M2-SQ-1419 M2-SQ-1519 M2-SQ-1619 M2-SQ-1719 M2-SQ-1819 M2-SQ-1919 M2-SQ-2019 M2-SQ-2119 M2-SQ-2219 M2-SQ-2319 M2-SQ-2419 M2-SQ-1218 M2-SQ-1318 M2-SQ-1418 M2-SQ-1518 M2-SQ-1618 M2-SQ-1718 M2-SQ-1818 M2-SQ-1918 M2-SQ-2018 M2-SQ-2118 M2-SQ-2218 M2-SQ-2318 M2-SQ-2418 M2-SQ-1117 M2-SQ-1217 M2-SQ-1317 M2-SQ-1417 M2-SQ-1517 M2-SQ-1617 M2-SQ-1717 M2-SQ-1817 M2-SQ-1917 M2-SQ-2017 M2-SQ-2117 M2-SQ-2217 M2-SQ-2317 M2-SQ-2417 M2-SQ-1016 M2-SQ-1116 M2-SQ-1216 M2-SQ-1316 M2-SQ-1416 M2-SQ-1516 M2-SQ-1616 M2-SQ-1716 M2-SQ-1816 M2-SQ-1916 M2-SQ-2016 M2-SQ-2116 M2-SQ-2216 M2-SQ-2316 M2-SQ-2416 M2-SQ-1015 M2-SQ-1115 M2-SQ-1215 M2-SQ-1315 M2-SQ-1415 M2-SQ-1515 M2-SQ-1615 M2-SQ-1715 M2-SQ-1815 M2-SQ-1915 M2-SQ-2015 M2-SQ-1014 M2-SQ-1114 M2-SQ-1214 M2-SQ-1314 M2-SQ-1414 M2-SQ-1514 M2-SQ-1614 M2-SQ-1714 M2-SQ-1814 M2-SQ-1914 M2-SQ-1013 M2-SQ-1113 M2-SQ-1213 M2-SQ-1313 M2-SQ-1413 M2-SQ-1513 M2-SQ-1613 M2-SQ-1713 M2-SQ-1012 M2-SQ-1112 M2-SQ-1212 M2-SQ-1312 M2-SQ-1412 M2-SQ-1512 M2-SQ-1612 M2-SQ-1712 M2-SQ-1011 M2-SQ-1111 M2-SQ-1211 M2-SQ-1311 M2-SQ-1411 M2-SQ-1511 M2-SQ-1010 M2-SQ-1110 M2-SQ-1210 M2-SQ-1310 M2-SQ-1410 M2-SQ-1510 QUESTIONS? PLEASE CONTACT CUSTOMER SERVICE F ASSISTANCE M2 DER FM Patient Reference: PAGE 2 of 9

3 ANTI-THRUST SELECTED F INCONTINENCE PROTECTION SELECTED F AIR TRANSMISSION M2-FA-1824 M2-FA-1924 M2-FA-2024 M2-FA-2124 M2-FA-2224 M2-FA-2324 M2-FA-2424 M2-FA-1823 M2-FA-1923 M2-FA-2023 M2-FA-2123 M2-FA-2223 M2-FA-2323 M2-FA-2423 M2-FA-1622 M2-FA-1722 M2-FA-1822 M2-FA-1922 M2-FA-2022 M2-FA-2122 M2-FA-2222 M2-FA-2322 M2-FA-2422 M2-FA-1521 M2-FA-1621 M2-FA-1721 M2-FA-1821 M2-FA-1921 M2-FA-2021 M2-FA-2121 M2-FA-2221 M2-FA-2321 M2-FA-2421 M2-FA-1420 M2-FA-1520 M2-FA-1620 M2-FA-1720 M2-FA-1820 M2-FA-1920 M2-FA-2020 M2-FA-2120 M2-FA-2220 M2-FA-2320 M2-FA-2420 M2-FA-1419 M2-FA-1519 M2-FA-1619 M2-FA-1719 M2-FA-1819 M2-FA-1919 M2-FA-2019 M2-FA-2119 M2-FA-2219 M2-FA-2319 M2-FA-2419 M2-FA-1218 M2-FA-1318 M2-FA-1418 M2-FA-1518 M2-FA-1618 M2-FA-1718 M2-FA-1818 M2-FA-1918 M2-FA-2018 M2-FA-2118 M2-FA-2218 M2-FA-2318 M2-FA-2418 M2-FA-1117 M2-FA-1217 M2-FA-1317 M2-FA-1417 M2-FA-1517 M2-FA-1617 M2-FA-1717 M2-FA-1817 M2-FA-1917 M2-FA-2017 M2-FA-2117 M2-FA-2217 M2-FA-2317 M2-FA-2417 M2-FA-1016 M2-FA-1116 M2-FA-1216 M2-FA-1316 M2-FA-1416 M2-FA-1516 M2-FA-1616 M2-FA-1716 M2-FA-1816 M2-FA-1916 M2-FA-2016 M2-FA-2116 M2-FA-2216 M2-FA-2316 M2-FA-2416 M2-FA-1015 M2-FA-1115 M2-FA-1215 M2-FA-1315 M2-FA-1415 M2-FA-1515 M2-FA-1615 M2-FA-1715 M2-FA-1815 M2-FA-1915 M2-FA-2015 M2-FA-1014 M2-FA-1114 M2-FA-1214 M2-FA-1314 M2-FA-1414 M2-FA-1514 M2-FA-1614 M2-FA-1714 M2-FA-1814 M2-FA-1914 M2-FA-1013 M2-FA-1113 M2-FA-1213 M2-FA-1313 M2-FA-1413 M2-FA-1513 M2-FA-1613 M2-FA-1713 M2-FA-1012 M2-FA-1112 M2-FA-1212 M2-FA-1312 M2-FA-1412 M2-FA-1512 M2-FA-1612 M2-FA-1712 M2-FA-1011 M2-FA-1111 M2-FA-1211 M2-FA-1311 M2-FA-1411 M2-FA-1511 M2-FA-1010 M2-FA-1110 M2-FA-1210 M2-FA-1310 M2-FA-1410 M2-FA-1510 M2-SA-1824 M2-SA-1924 M2-SA-2024 M2-SA-2124 M2-SA-2224 M2-SA-2324 M2-SA-2424 M2-SA-1823 M2-SA-1923 M2-SA-2023 M2-SA-2123 M2-SA-2223 M2-SA-2323 M2-SA-2423 M2-SA-1622 M2-SA-1722 M2-SA-1822 M2-SA-1922 M2-SA-2022 M2-SA-2122 M2-SA-2222 M2-SA-2322 M2-SA-2422 M2-SA-1521 M2-SA-1621 M2-SA-1721 M2-SA-1821 M2-SA-1921 M2-SA-2021 M2-SA-2121 M2-SA-2221 M2-SA-2321 M2-SA-2421 M2-SA-1420 M2-SA-1520 M2-SA-1620 M2-SA-1720 M2-SA-1820 M2-SA-1920 M2-SA-2020 M2-SA-2120 M2-SA-2220 M2-SA-2320 M2-SA-2420 M2-SA-1419 M2-SA-1519 M2-SA-1619 M2-SA-1719 M2-SA-1819 M2-SA-1919 M2-SA-2019 M2-SA-2119 M2-SA-2219 M2-SA-2319 M2-SA-2419 M2-SA-1218 M2-SA-1318 M2-SA-1418 M2-SA-1518 M2-SA-1618 M2-SA-1718 M2-SA-1818 M2-SA-1918 M2-SA-2018 M2-SA-2118 M2-SA-2218 M2-SA-2318 M2-SA-2418 M2-SA-1117 M2-SA-1217 M2-SA-1317 M2-SA-1417 M2-SA-1517 M2-SA-1617 M2-SA-1717 M2-SA-1817 M2-SA-1917 M2-SA-2017 M2-SA-2117 M2-SA-2217 M2-SA-2317 M2-SA-2417 M2-SA-1016 M2-SA-1116 M2-SA-1216 M2-SA-1316 M2-SA-1416 M2-SA-1516 M2-SA-1616 M2-SA-1716 M2-SA-1816 M2-SA-1916 M2-SA-2016 M2-SA-2116 M2-SA-2216 M2-SA-2316 M2-SA-2416 M2-SA-1015 M2-SA-1115 M2-SA-1215 M2-SA-1315 M2-SA-1415 M2-SA-1515 M2-SA-1615 M2-SA-1715 M2-SA-1815 M2-SA-1915 M2-SA-2015 M2-SA-1014 M2-SA-1114 M2-SA-1214 M2-SA-1314 M2-SA-1414 M2-SA-1514 M2-SA-1614 M2-SA-1714 M2-SA-1814 M2-SA-1914 M2-SA-1013 M2-SA-1113 M2-SA-1213 M2-SA-1313 M2-SA-1413 M2-SA-1513 M2-SA-1613 M2-SA-1713 M2-SA-1012 M2-SA-1112 M2-SA-1212 M2-SA-1312 M2-SA-1412 M2-SA-1512 M2-SA-1612 M2-SA-1712 M2-SA-1011 M2-SA-1111 M2-SA-1211 M2-SA-1311 M2-SA-1411 M2-SA-1511 M2-SA-1010 M2-SA-1110 M2-SA-1210 M2-SA-1310 M2-SA-1410 M2-SA-1510 QUESTIONS? PLEASE CONTACT CUSTOMER SERVICE F ASSISTANCE M2 DER FM Patient Reference: PAGE 3 of 9

4 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 ANTI-THRUST with SELECTED F INCONTINENCE PROTECTION SELECTED F AIR TRANSMISSION with GLIDEWEAR M2-FQA-1824 M2-FQA-1924 M2-FQA-2024 M2-FQA-2124 M2-FQA-2224 M2-FQA-2324 M2-FQA-2424 M2-FQA-1823 M2-FQA-1923 M2-FQA-2023 M2-FQA-2123 M2-FQA-2223 M2-FQA-2323 M2-FQA-2423 M2-FQA-1622 M2-FQA-1722 M2-FQA-1822 M2-FQA-1922 M2-FQA-2022 M2-FQA-2122 M2-FQA-2222 M2-FQA-2322 M2-FQA-2422 M2-FQA-1521 M2-FQA-1621 M2-FQA-1721 M2-FQA-1821 M2-FQA-1921 M2-FQA-2021 M2-FQA-2121 M2-FQA-2221 M2-FQA-2321 M2-FQA-2421 M2-FQA-1420 M2-FQA-1520 M2-FQA-1620 M2-FQA-1720 M2-FQA-1820 M2-FQA-1920 M2-FQA-2020 M2-FQA-2120 M2-FQA-2220 M2-FQA-2320 M2-FQA-2420 M2-FQA-1419 M2-FQA-1519 M2-FQA-1619 M2-FQA-1719 M2-FQA-1819 M2-FQA-1919 M2-FQA-2019 M2-FQA-2119 M2-FQA-2219 M2-FQA-2319 M2-FQA-2419 M2-FQA-1218 M2-FQA-1318 M2-FQA-1418 M2-FQA-1518 M2-FQA-1618 M2-FQA-1718 M2-FQA-1818 M2-FQA-1918 M2-FQA-2018 M2-FQA-2118 M2-FQA-2218 M2-FQA-2318 M2-FQA-2418 M2-FQA-1117 M2-FQA-1217 M2-FQA-1317 M2-FQA-1417 M2-FQA-1517 M2-FQA-1617 M2-FQA-1717 M2-FQA-1817 M2-FQA-1917 M2-FQA-2017 M2-FQA-2117 M2-FQA-2217 M2-FQA-2317 M2-FQA-2417 M2-FQA-1016 M2-FQA-1116 M2-FQA-1216 M2-FQA-1316 M2-FQA-1416 M2-FQA-1516 M2-FQA-1616 M2-FQA-1716 M2-FQA-1816 M2-FQA-1916 M2-FQA-2016 M2-FQA-2116 M2-FQA-2216 M2-FQA-2316 M2-FQA-2416 M2-FQA-1015 M2-FQA-1115 M2-FQA-1215 M2-FQA-1315 M2-FQA-1415 M2-FQA-1515 M2-FQA-1615 M2-FQA-1715 M2-FQA-1815 M2-FQA-1915 M2-FQA-2015 M2-FQA-1014 M2-FQA-1114 M2-FQA-1214 M2-FQA-1314 M2-FQA-1414 M2-FQA-1514 M2-FQA-1614 M2-FQA-1714 M2-FQA-1814 M2-FQA-1914 M2-FQA-1013 M2-FQA-1113 M2-FQA-1213 M2-FQA-1313 M2-FQA-1413 M2-FQA-1513 M2-FQA-1613 M2-FQA-1713 M2-FQA-1012 M2-FQA-1112 M2-FQA-1212 M2-FQA-1312 M2-FQA-1412 M2-FQA-1512 M2-FQA-1612 M2-FQA-1712 M2-FQA-1011 M2-FQA-1111 M2-FQA-1211 M2-FQA-1311 M2-FQA-1411 M2-FQA-1511 M2-FQA-1010 M2-FQA-1110 M2-FQA-1210 M2-FQA-1310 M2-FQA-1410 M2-FQA-1510 with GLIDEWEAR M2-SQA-1824 M2-SQA-1924 M2-SQA-2024 M2-SQA-2124 M2-SQA-2224 M2-SQA-2324 M2-SQA-2424 M2-SQA-1823 M2-SQA-1923 M2-SQA-2023 M2-SQA-2123 M2-SQA-2223 M2-SQA-2323 M2-SQA-2423 M2-SQA-1622 M2-SQA-1722 M2-SQA-1822 M2-SQA-1922 M2-SQA-2022 M2-SQA-2122 M2-SQA-2222 M2-SQA-2322 M2-SQA-2422 M2-SQA-1521 M2-SQA-1621 M2-SQA-1721 M2-SQA-1821 M2-SQA-1921 M2-SQA-2021 M2-SQA-2121 M2-SQA-2221 M2-SQA-2321 M2-SQA-2421 M2-SQA-1420 M2-SQA-1520 M2-SQA-1620 M2-SQA-1720 M2-SQA-1820 M2-SQA-1920 M2-SQA-2020 M2-SQA-2120 M2-SQA-2220 M2-SQA-2320 M2-SQA-2420 M2-SQA-1419 M2-SQA-1519 M2-SQA-1619 M2-SQA-1719 M2-SQA-1819 M2-SQA-1919 M2-SQA-2019 M2-SQA-2119 M2-SQA-2219 M2-SQA-2319 M2-SQA-2419 M2-SQA-1218 M2-SQA-1318 M2-SQA-1418 M2-SQA-1518 M2-SQA-1618 M2-SQA-1718 M2-SQA-1818 M2-SQA-1918 M2-SQA-2018 M2-SQA-2118 M2-SQA-2218 M2-SQA-2318 M2-SQA-2418 M2-SQA-1117 M2-SQA-1217 M2-SQA-1317 M2-SQA-1417 M2-SQA-1517 M2-SQA-1617 M2-SQA-1717 M2-SQA-1817 M2-SQA-1917 M2-SQA-2017 M2-SQA-2117 M2-SQA-2217 M2-SQA-2317 M2-SQA-2417 M2-SQA-1016 M2-SQA-1116 M2-SQA-1216 M2-SQA-1316 M2-SQA-1416 M2-SQA-1516 M2-SQA-1616 M2-SQA-1716 M2-SQA-1816 M2-SQA-1916 M2-SQA-2016 M2-SQA-2116 M2-SQA-2216 M2-SQA-2316 M2-SQA-2416 M2-SQA-1015 M2-SQA-1115 M2-SQA-1215 M2-SQA-1315 M2-SQA-1415 M2-SQA-1515 M2-SQA-1615 M2-SQA-1715 M2-SQA-1815 M2-SQA-1915 M2-SQA-2015 M2-SQA-1014 M2-SQA-1114 M2-SQA-1214 M2-SQA-1314 M2-SQA-1414 M2-SQA-1514 M2-SQA-1614 M2-SQA-1714 M2-SQA-1814 M2-SQA-1914 M2-SQA-1013 M2-SQA-1113 M2-SQA-1213 M2-SQA-1313 M2-SQA-1413 M2-SQA-1513 M2-SQA-1613 M2-SQA-1713 M2-SQA-1012 M2-SQA-1112 M2-SQA-1212 M2-SQA-1312 M2-SQA-1412 M2-SQA-1512 M2-SQA-1612 M2-SQA-1712 M2-SQA-1011 M2-SQA-1111 M2-SQA-1211 M2-SQA-1311 M2-SQA-1411 M2-SQA-1511 M2-SQA-1010 M2-SQA-1110 M2-SQA-1210 M2-SQA-1310 M2-SQA-1410 M2-SQA-1510 QUESTIONS? PLEASE CONTACT CUSTOMER SERVICE F ASSISTANCE M2 DER FM Patient Reference: PAGE 4 of 9

5 WEDGE SELECTED F INCONTINENCE PROTECTION SELECTED F AIR TRANSMISSION M2-FW-1824 M2-FW-1924 M2-FW-2024 M2-FW-2124 M2-FW-2224 M2-FW-2324 M2-FW-2424 M2-FW-1823 M2-FW-1923 M2-FW-2023 M2-FW-2123 M2-FW-2223 M2-FW-2323 M2-FW-2423 M2-FW-1622 M2-FW-1722 M2-FW-1822 M2-FW-1922 M2-FW-2022 M2-FW-2122 M2-FW-2222 M2-FW-2322 M2-FW-2422 M2-FW-1521 M2-FW-1621 M2-FW-1721 M2-FW-1821 M2-FW-1921 M2-FW-2021 M2-FW-2121 M2-FW-2221 M2-FW-2321 M2-FW-2421 M2-FW-1420 M2-FW-1520 M2-FW-1620 M2-FW-1720 M2-FW-1820 M2-FW-1920 M2-FW-2020 M2-FW-2120 M2-FW-2220 M2-FW-2320 M2-FW-2420 M2-FW-1419 M2-FW-1519 M2-FW-1619 M2-FW-1719 M2-FW-1819 M2-FW-1919 M2-FW-2019 M2-FW-2119 M2-FW-2219 M2-FW-2319 M2-FW-2419 M2-FW-1218 M2-FW-1318 M2-FW-1418 M2-FW-1518 M2-FW-1618 M2-FW-1718 M2-FW-1818 M2-FW-1918 M2-FW-2018 M2-FW-2118 M2-FW-2218 M2-FW-2318 M2-FW-2418 M2-FW-1117 M2-FW-1217 M2-FW-1317 M2-FW-1417 M2-FW-1517 M2-FW-1617 M2-FW-1717 M2-FW-1817 M2-FW-1917 M2-FW-2017 M2-FW-2117 M2-FW-2217 M2-FW-2317 M2-FW-2417 M2-FW-1016 M2-FW-1116 M2-FW-1216 M2-FW-1316 M2-FW-1416 M2-FW-1516 M2-FW-1616 M2-FW-1716 M2-FW-1816 M2-FW-1916 M2-FW-2016 M2-FW-2116 M2-FW-2216 M2-FW-2316 M2-FW-2416 M2-FW-1015 M2-FW-1115 M2-FW-1215 M2-FW-1315 M2-FW-1415 M2-FW-1515 M2-FW-1615 M2-FW-1715 M2-FW-1815 M2-FW-1915 M2-FW-2015 M2-FW-1014 M2-FW-1114 M2-FW-1214 M2-FW-1314 M2-FW-1414 M2-FW-1514 M2-FW-1614 M2-FW-1714 M2-FW-1814 M2-FW-1914 M2-FW-1013 M2-FW-1113 M2-FW-1213 M2-FW-1313 M2-FW-1413 M2-FW-1513 M2-FW-1613 M2-FW-1713 M2-FW-1012 M2-FW-1112 M2-FW-1212 M2-FW-1312 M2-FW-1412 M2-FW-1512 M2-FW-1612 M2-FW-1712 M2-FW-1011 M2-FW-1111 M2-FW-1211 M2-FW-1311 M2-FW-1411 M2-FW-1511 M2-FW-1010 M2-FW-1110 M2-FW-1210 M2-FW-1310 M2-FW-1410 M2-FW-1510 M2-SW-1824 M2-SW-1924 M2-SW-2024 M2-SW-2124 M2-SW-2224 M2-SW-2324 M2-SW-2424 M2-SW-1823 M2-SW-1923 M2-SW-2023 M2-SW-2123 M2-SW-2223 M2-SW-2323 M2-SW-2423 M2-SW-1622 M2-SW-1722 M2-SW-1822 M2-SW-1922 M2-SW-2022 M2-SW-2122 M2-SW-2222 M2-SW-2322 M2-SW-2422 M2-SW-1521 M2-SW-1621 M2-SW-1721 M2-SW-1821 M2-SW-1921 M2-SW-2021 M2-SW-2121 M2-SW-2221 M2-SW-2321 M2-SW-2421 M2-SW-1420 M2-SW-1520 M2-SW-1620 M2-SW-1720 M2-SW-1820 M2-SW-1920 M2-SW-2020 M2-SW-2120 M2-SW-2220 M2-SW-2320 M2-SW-2420 M2-SW-1419 M2-SW-1519 M2-SW-1619 M2-SW-1719 M2-SW-1819 M2-SW-1919 M2-SW-2019 M2-SW-2119 M2-SW-2219 M2-SW-2319 M2-SW-2419 M2-SW-1218 M2-SW-1318 M2-SW-1418 M2-SW-1518 M2-SW-1618 M2-SW-1718 M2-SW-1818 M2-SW-1918 M2-SW-2018 M2-SW-2118 M2-SW-2218 M2-SW-2318 M2-SW-2418 M2-SW-1117 M2-SW-1217 M2-SW-1317 M2-SW-1417 M2-SW-1517 M2-SW-1617 M2-SW-1717 M2-SW-1817 M2-SW-1917 M2-SW-2017 M2-SW-2117 M2-SW-2217 M2-SW-2317 M2-SW-2417 M2-SW-1016 M2-SW-1116 M2-SW-1216 M2-SW-1316 M2-SW-1416 M2-SW-1516 M2-SW-1616 M2-SW-1716 M2-SW-1816 M2-SW-1916 M2-SW-2016 M2-SW-2116 M2-SW-2216 M2-SW-2316 M2-SW-2416 M2-SW-1015 M2-SW-1115 M2-SW-1215 M2-SW-1315 M2-SW-1415 M2-SW-1515 M2-SW-1615 M2-SW-1715 M2-SW-1815 M2-SW-1915 M2-SW-2015 M2-SW-1014 M2-SW-1114 M2-SW-1214 M2-SW-1314 M2-SW-1414 M2-SW-1514 M2-SW-1614 M2-SW-1714 M2-SW-1814 M2-SW-1914 M2-SW-1013 M2-SW-1113 M2-SW-1213 M2-SW-1313 M2-SW-1413 M2-SW-1513 M2-SW-1613 M2-SW-1713 M2-SW-1012 M2-SW-1112 M2-SW-1212 M2-SW-1312 M2-SW-1412 M2-SW-1512 M2-SW-1612 M2-SW-1712 M2-SW-1011 M2-SW-1111 M2-SW-1211 M2-SW-1311 M2-SW-1411 M2-SW-1511 M2-SW-1010 M2-SW-1110 M2-SW-1210 M2-SW-1310 M2-SW-1410 M2-SW-1510 QUESTIONS? PLEASE CONTACT CUSTOMER SERVICE F ASSISTANCE M2 DER FM Patient Reference: PAGE 5 of 9

6 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 WEDGE with SELECTED F INCONTINENCE PROTECTION SELECTED F AIR TRANSMISSION with GLIDEWEAR M2-FQW-1824 M2-FQW-1924 M2-FQW-2024 M2-FQW-2124 M2-FQW-2224 M2-FQW-2324 M2-FQW-2424 M2-FQW-1823 M2-FQW-1923 M2-FQW-2023 M2-FQW-2123 M2-FQW-2223 M2-FQW-2323 M2-FQW-2423 M2-FQW-1622 M2-FQW-1722 M2-FQW-1822 M2-FQW-1922 M2-FQW-2022 M2-FQW-2122 M2-FQW-2222 M2-FQW-2322 M2-FQW-2422 M2-FQW-1521 M2-FQW-1621 M2-FQW-1721 M2-FQW-1821 M2-FQW-1921 M2-FQW-2021 M2-FQW-2121 M2-FQW-2221 M2-FQW-2321 M2-FQW-2421 M2-FQW-1420 M2-FQW-1520 M2-FQW-1620 M2-FQW-1720 M2-FQW-1820 M2-FQW-1920 M2-FQW-2020 M2-FQW-2120 M2-FQW-2220 M2-FQW-2320 M2-FQW-2420 M2-FQW-1419 M2-FQW-1519 M2-FQW-1619 M2-FQW-1719 M2-FQW-1819 M2-FQW-1919 M2-FQW-2019 M2-FQW-2119 M2-FQW-2219 M2-FQW-2319 M2-FQW-2419 M2-FQW-1218 M2-FQW-1318 M2-FQW-1418 M2-FQW-1518 M2-FQW-1618 M2-FQW-1718 M2-FQW-1818 M2-FQW-1918 M2-FQW-2018 M2-FQW-2118 M2-FQW-2218 M2-FQW-2318 M2-FQW-2418 M2-FQW-1117 M2-FQW-1217 M2-FQW-1317 M2-FQW-1417 M2-FQW-1517 M2-FQW-1617 M2-FQW-1717 M2-FQW-1817 M2-FQW-1917 M2-FQW-2017 M2-FQW-2117 M2-FQW-2217 M2-FQW-2317 M2-FQW-2417 M2-FQW-1016 M2-FQW-1116 M2-FQW-1216 M2-FQW-1316 M2-FQW-1416 M2-FQW-1516 M2-FQW-1616 M2-FQW-1716 M2-FQW-1816 M2-FQW-1916 M2-FQW-2016 M2-FQW-2116 M2-FQW-2216 M2-FQW-2316 M2-FQW-2416 M2-FQW-1015 M2-FQW-1115 M2-FQW-1215 M2-FQW-1315 M2-FQW-1415 M2-FQW-1515 M2-FQW-1615 M2-FQW-1715 M2-FQW-1815 M2-FQW-1915 M2-FQW-2015 M2-FQW-1014 M2-FQW-1114 M2-FQW-1214 M2-FQW-1314 M2-FQW-1414 M2-FQW-1514 M2-FQW-1614 M2-FQW-1714 M2-FQW-1814 M2-FQW-1914 M2-FQW-1013 M2-FQW-1113 M2-FQW-1213 M2-FQW-1313 M2-FQW-1413 M2-FQW-1513 M2-FQW-1613 M2-FQW-1713 M2-FQW-1012 M2-FQW-1112 M2-FQW-1212 M2-FQW-1312 M2-FQW-1412 M2-FQW-1512 M2-FQW-1612 M2-FQW-1712 M2-FQW-1011 M2-FQW-1111 M2-FQW-1211 M2-FQW-1311 M2-FQW-1411 M2-FQW-1511 M2-FQW-1010 M2-FQW-1110 M2-FQW-1210 M2-FQW-1310 M2-FQW-1410 M2-FQW-1510 with GLIDEWEAR M2-SQW-1824 M2-SQW-1924 M2-SQW-2024 M2-SQW-2124 M2-SQW-2224 M2-SQW-2324 M2-SQW-2424 M2-SQW-1823 M2-SQW-1923 M2-SQW-2023 M2-SQW-2123 M2-SQW-2223 M2-SQW-2323 M2-SQW-2423 M2-SQW-1622 M2-SQW-1722 M2-SQW-1822 M2-SQW-1922 M2-SQW-2022 M2-SQW-2122 M2-SQW-2222 M2-SQW-2322 M2-SQW-2422 M2-SQW-1521 M2-SQW-1621 M2-SQW-1721 M2-SQW-1821 M2-SQW-1921 M2-SQW-2021 M2-SQW-2121 M2-SQW-2221 M2-SQW-2321 M2-SQW-2421 M2-SQW-1420 M2-SQW-1520 M2-SQW-1620 M2-SQW-1720 M2-SQW-1820 M2-SQW-1920 M2-SQW-2020 M2-SQW-2120 M2-SQW-2220 M2-SQW-2320 M2-SQW-2420 M2-SQW-1419 M2-SQW-1519 M2-SQW-1619 M2-SQW-1719 M2-SQW-1819 M2-SQW-1919 M2-SQW-2019 M2-SQW-2119 M2-SQW-2219 M2-SQW-2319 M2-SQW-2419 M2-SQW-1218 M2-SQW-1318 M2-SQW-1418 M2-SQW-1518 M2-SQW-1618 M2-SQW-1718 M2-SQW-1818 M2-SQW-1918 M2-SQW-2018 M2-SQW-2118 M2-SQW-2218 M2-SQW-2318 M2-SQW-2418 M2-SQW-1117 M2-SQW-1217 M2-SQW-1317 M2-SQW-1417 M2-SQW-1517 M2-SQW-1617 M2-SQW-1717 M2-SQW-1817 M2-SQW-1917 M2-SQW-2017 M2-SQW-2117 M2-SQW-2217 M2-SQW-2317 M2-SQW-2417 M2-SQW-1016 M2-SQW-1116 M2-SQW-1216 M2-SQW-1316 M2-SQW-1416 M2-SQW-1516 M2-SQW-1616 M2-SQW-1716 M2-SQW-1816 M2-SQW-1916 M2-SQW-2016 M2-SQW-2116 M2-SQW-2216 M2-SQW-2316 M2-SQW-2416 M2-SQW-1015 M2-SQW-1115 M2-SQW-1215 M2-SQW-1315 M2-SQW-1415 M2-SQW-1515 M2-SQW-1615 M2-SQW-1715 M2-SQW-1815 M2-SQW-1915 M2-SQW-2015 M2-SQW-1014 M2-SQW-1114 M2-SQW-1214 M2-SQW-1314 M2-SQW-1414 M2-SQW-1514 M2-SQW-1614 M2-SQW-1714 M2-SQW-1814 M2-SQW-1914 M2-SQW-1013 M2-SQW-1113 M2-SQW-1213 M2-SQW-1313 M2-SQW-1413 M2-SQW-1513 M2-SQW-1613 M2-SQW-1713 M2-SQW-1012 M2-SQW-1112 M2-SQW-1212 M2-SQW-1312 M2-SQW-1412 M2-SQW-1512 M2-SQW-1612 M2-SQW-1712 M2-SQW-1011 M2-SQW-1111 M2-SQW-1211 M2-SQW-1311 M2-SQW-1411 M2-SQW-1511 M2-SQW-1010 M2-SQW-1110 M2-SQW-1210 M2-SQW-1310 M2-SQW-1410 M2-SQW-1510 QUESTIONS? PLEASE CONTACT CUSTOMER SERVICE F ASSISTANCE M2 DER FM Patient Reference: PAGE 6 of 9

7 2 M2 ACCESSIES *All accessories are cosmetic changes to the cushion except for options in gray, which are add on items. 2.1 GROWTH NOTCHES MSRP $ RAIL CUTS MSRP $ COL - COMES STANDARD SILVER REFLECTIVE 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. DEPTH 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 COL LOCATION C = 1 D (GROWTH-NOTCH-1) B = 1 Rail Cut (RAIL-CUT-1.0) Red (RED) Blue (BLUE) C = 2 D (GROWTH-NOTCH-2) B = 1½ Rail Cut (RAIL-CUT-1.5) Purple (PURPLE) Green (GREEN) C = 3 D (GROWTH-NOTCH-3) B = 2 Rail Cut (RAIL-CUT-2.0) Pink (PINK) Remove (REMOVE) C =Other (GROWTH-NOTCH-OTHER) Orange (ANGE) 2.4 KWIK STRAP MSRP $ INCONTINENCE LINER 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 Kwik Strap (KWIK-STRAP) One Extra Incontinence Liner (INCON-LINER) Two Extra Incontinence Liners (INCON-LINER) 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 SOLID SEAT PAN & HARDWARE KIT HCPCS Code: E2231 MSRP $ RIGID 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. Lateral thigh support hardware can be easily attached. 3/ Plastic rigidizing board. Solid Seat Pan & Hardware Kit (RSSP-N-HARD) Rigid Insert Glued (RGD-INSERT-GLUED) Rigid Insert Not Glued (RGD-INSERT-UNGLUED) M2 DER FM Patient Reference: PAGE 7 of 9

8 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 TT HARDWARE, SLOT MOUNT TT HARDWARE SLOT MOUNT- FIXED TT HARDWARE 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. HARDWARE SIZE V. CUSHION SMALL MEDIUM LARGE HARDWARE SIZE MAX CUSHION CLEARANCE RECOMMENDED CUSHION 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 E1028 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 M2 DER FM Patient Reference: PAGE 8 of 9

9 B. TT HARDWARE, POWER MOUNT HARDWARE SIZE V. CUSHION TT HARDWARE POWER MOUNT- FIXED TT HARDWARE POWER MOUNT SMALL MEDIUM LARGE HARDWARE SIZE MAX CUSHION CLEARANCE RECOMMENDED CUSHION SMALL MEDIUM LARGE SIZE MSRP LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT FIXED E1028 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 TT HARDWARE, 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- NO MEDIAL 1 MEDIAL HARDWARE MAX CUSHION CLEARANCE RECOMMENDED CUSHION NO MEDIAL * MEDIAL * *If you need to increase the height or medial reach, add additional links in section 2.2. 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 E1028 $ BL-LPTS-GT2RMS-LH BL-LPTS-GT2RMS-LH BL-LPTS-GT2RMS-RH BL-LPTS-GT2RMS-RH 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 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 M2 DER FM Patient Reference: SUBMIT BY PAGE 9 of 9