Liberty X - Cloudfront.net

LIBERTY® X
ORDER FORM
Company Name/ACCT #:
HCPCS CODING: E2622
ADJUSTABLE SKIN PROTECTION
P.O. Number:
Liberty® X shown with GlideWear®
Requested By:
Liberty® X Liner and Foam Base
Phone:
Fax:
Email:
Ship To:
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.
SIZE & STYLE
Please select size in the appropriate fabric chart below.
COMFORT-TEK™
SELECTED FOR INCONTINENCE PROTECTION
& AN EASILY CLEANED SURFACE.
STRETCH-AIR™
$462.19
$462.19
DEPTH
LBX-F-1820
LBX-F-2020
LBX-F-1818
LBX-F-2018
19”
LBX-F-1618
17”
16”
LBX-F-1717
LBX-F-1616
16”
SELECTED FOR AIR TRANSMISSION
& HEAT DISSIPATION.
COMFORT-TEK™
20”
18”
STRETCH-AIR™
OR
20”
DEPTH
1
17”
18”
19”
LBX-S-2020
LBX-S-1818
LBX-S-2018
19”
18”
LBX-S-1618
17”
16”
LBX-F-1816
LBX-S-1820
20”
LBX-S-1717
LBX-S-1616
16”
LBX-S-1816
17”
WIDTH
18”
19”
20”
WIDTH
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
COMFORT-TEK™ with GLIDEWEAR®
STRETCH-AIR™ with GLIDEWEAR®
$499.50
$499.50
LBX-FQ-1820
LBX-FQ-2020
LBX-FQ-1818
LBX-FQ-2018
19”
18”
LBX-FQ-1618
17”
16”
LBX-FQ-1717
LBX-FQ-1616
16”
18”
19”
20”
LBX-SQ-1820
LBX-SQ-2020
LBX-SQ-1818
LBX-SQ-2018
19”
18”
LBX-SQ-1618
17”
16”
LBX-FQ-1816
17”
20”
DEPTH
DEPTH
20”
LBX-SQ-1717
LBX-SQ-1616
16”
LBX-SQ-1816
17”
WIDTH
18”
19”
20”
WIDTH
QUESTIONS? PLEASE CONTACT CUSTOMER SERVICE FOR ASSISTANCE. | 800.564.9248
Liberty® X is not recommended for use in altitudes above 3,000 ft.
LIBERTY® X ORDER FORM
Patient Reference:
PAGE 1 of 3
LIBERTY-X-ORDER REV0316
Patient Reference:
2
2.1
*All accessories are cosmetic changes to the cushion
except for options in gray, which are add on items.
LIBERTY® X ACCESSORIES
COLOR - COMES STANDARD W/
REFLECTIVE BLUE PIPING
MSRP $25.00
Accent colors can be applied to the cushion via
colored piping. If no colors are selected, our standard
reflective blue piping is used.
KWIK STRAP®
2.2 MSRP
$15.00
2.3
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.
INCONTINENCE LINER
MSRP One = $58.00 - Two = $116.00
Liner provides extra incontinence protection
for the cushion.
Rear View
COLOR LOCATION
Red (RED)
Silver Reflective (SILVER)
Purple (PURPLE)
Green (GREEN)
Pink (PINK)
Remove (REMOVE)
COVER
2.4 EXTRA
MSRP One = $60.00 - Two = $120.00
One Extra Incontinence Liner (INCON-LINER)
Kwik Strap®
Two Extra Incontinence Liners (INCON-LINER)
(KWIK-STRAP)
REMOVABLE SOLID SEAT
2.5 PAN & HARDWARE KIT
HCPCS Code: E2231
MSRP $375.00
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 trunk supports can be easily attached.
2.6
RIGID INSERT
HCPCS Code: E0992
MSRP $63.00
3/16” Plastic rigidizing board.
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)
Solid Seat Pan & Hardware Kit
Two Extra Comfort Tek Outer Cover
(RSSP-N-HARD)
(2X-COMFORT-TEK-CV)
(RGD-INSERT-UNGLUED)
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)
LIBERTY® X ORDER FORM
LIBERTY-X-ORDER REV0316
2.7
Rigid Insert Not Glued
Patient Reference:
PAGE 2 of 3
3
3.1
LATERAL THIGH SUPPORTS & HARDWARE
RIGID
RIGID CONTOURED
MSRP $50.00/ea
*Length (L) refers to the actual size dimension
of the support from bottom to top edge.
Select a left and/or right lateral pad using any
combination of style, size and fabric.
Contact Customer Service for custom sizes
that are not listed below. 1.800.564.9248.
LATERAL THIGH SUPPORT PADS
HCPCS Code: E0956 (OPTIONAL)
INSTRUCTIONS:
for Anti-Thrust Cushion
MSRP $50.00/ea
NOTE:
T-Nut spacing along
hip guide is 1” on
center running the
entire length of the
pad.
L
L
D
STRETCH-AIR
STRETCH-AIR
FABRIC
Extra L
SIZE
Left
FABRIC
Right
Extra R
Extra L
Left
SIZE
Right
Extra R
(HG1RS3H4D)
3” L x 4” D
(HG1RS3H4D)
(HG1RS3H4D-AL)
3” L x 4” D
(HG1RS3H4D-AR)
(HG1RS3H5D)
3” L x 5” D
(HG1RS3H5D)
(HG1RS3H5D-AL)
3” L x 5” D
(HG1RS3H5D-AR)
(HG1RS4H4D)
4” L x 4” D
(HG1RS4H4D)
(HG1RS4H4D-AL)
4” L x 4” D
(HG1RS4H4D-AR)
STRETCH-AIR
(HG1RS4H6D)
4” L x 6” D
(HG1RS4H6D)
(HG1RS4H6D-AL)
4” L x 6” D
(HG1RS4H6D-AR)
SELECTED FOR AIR
TRANSMISSION &
HEAT DISSIPATION.
(HG1RS4H8D)
4” L x 8” D
(HG1RS4H8D)
(HG1RS4H8D-AL)
4” L x 8” D
(HG1RS4H8D-AR)
(HG1RS4H10D)
4” L x 10” D
(HG1RS4H10D)
(HG1RS4H10D-AL)
4” L x 10” D
(HG1RS4H10D-AR)
(HG1RS4H12D)
4” L x 12” D
(HG1RS4H12D)
(HG1RS4H12D-AL)
4” L x 12” D
(HG1RS4H12D-AR)
(HG1RS4H14D)
4” L x 14” D
(HG1RS4H14D)
(HG1RS4H14D-AL)
4” L x 14” D
(HG1RS4H14D-AR)
(HG1RS4H16D)
4” L x 16” D
(HG1RS4H16D)
(HG1RS4H16D-AL)
4” L x 16” D
(HG1RS4H16D-AR)
- OR -
- OR -
COMFORT-TEK
COMFORT-TEK
FABRIC
Extra L
COMFORT-TEK
SELECTED FOR
INCONTINENCE
PROTECTION & AN
EASILY CLEANED
SURFACE.
Left
SIZE
FABRIC
Right
Extra L
Left
SIZE
Right
Extra R
3” L x 4” D
(HG1RF3H4D)
(HG1RF3H4D-AL)
3” L x 4” D
(HG1RF3H4D-AR)
(HG1RF3H5D)
3” L x 5” D
(HG1RF3H5D)
(HG1RF3H5D-AL)
3” L x 5” D
(HG1RF3H5D-AR)
(HG1RF4H4D)
4” L x 4” D
(HG1RF4H4D)
(HG1RF4H4D-AL)
4” L x 4” D
(HG1RF4H4D-AR)
(HG1RF4H6D)
4” L x 6” D
(HG1RF4H6D)
(HG1RF4H6D-AL)
4” L x 6” D
(HG1RF4H6D-AR)
(HG1RF4H8D)
4” L x 8” D
(HG1RF4H8D)
(HG1RF4H8D-AL)
4” L x 8” D
(HG1RF4H8D-AR)
(HG1RF4H10D)
4” L x 10” D
(HG1RF4H10D)
(HG1R4H10D-AL)
4” L x 10” D
(HG1RF4H10D-AR)
(HG1RF4H12D)
4” L x 12” D
(HG1RF4H12D)
(HG1R4H12D-AL)
4” L x 12” D
(HG1RF4H12D-AR)
(HG1RF4H14D)
4” L x 14” D
(HG1RF4H14D)
(HG1R4H14D-AL)
4” L x 14” D
(HG1RF4H14D-AR)
(HG1RF4H16D)
4” L x 16” D
(HG1RF4H16D)
(HG1R4H16D-AL)
4” L x 16” D
(HG1RF4H16D-AR)
NOTE: Lateral thigh support hardware will allow for width adjustability.
Hardware in Section A comes standard with 2 links. Each extra link in Section B
allows for 1” of adjustability.
LATERAL THIGH SUPPORT HARDWARE
HCPCS Code: E0956 (OPTIONAL)
A.
Extra R
(HG1RF3H4D)
REMOVABLE
B.
FIXED
- OR -
MSRP $240.00/ea
MSRP $100.00/ea
ADDITIONAL LINK
MSRP $35.00/extra link
SEE DETAIL A
ANGLE
ADJUSTABLE
ANGLE
ADJUSTABLE
RELEASE
5”
SEE DETAIL A
5”
1”
SEE DETAIL B
SEE DETAIL A
5”
5”
SEE DETAIL B
LEFT (HGL-QR)
RIGHT (HGR-QR)
(1) EXTRA L
(1) EXTRA R
(2) EXTRA L
(2) EXTRA R
LEFT (HG1-LINK)
RIGHT (HG1-LINK)
LEFT (HGL-RS)
RIGHT (HGR-RS)
(1) EXTRA L
(1) EXTRA R
(1) EXTRA L
(1) EXTRA R
(2) EXTRA L
(2) EXTRA R
(2) EXTRA L
(2) EXTRA R
(3) EXTRA L
(3) EXTRA R
SEE DETAIL B
LIBERTY® X ORDER FORM
Patient Reference:
SUBMIT BY EMAIL
PAGE 3 of 3
LIBERTY-X-ORDER REV0316
3.2
D