MAXX-ORDER REV013019 MAXX ORDER FORM Patient Reference: PAGE 1 of 6 *DO NOT SEND PATIENT PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.* SIZE & STYLE 1 MAXX ® ORDER FORM HCPCS CODING: E2607/E2608 SKIN PROTECTION & POSITIONING SEAT CUSHION MAXX ® shown with GlideWear ® DEPTH DEPTH WIDTH WIDTH MAXFF1620 MAXFF1720 MAXFF1820 MAXFF1920 MAXFF2020 MAXFF2120 MAXFF2220 MAXFF2320 MAXFF2420 MAXFF1619 MAXFF1719 MAXFF1819 MAXFF1919 MAXFF2019 MAXFF2119 MAXFF2219 MAXFF2319 MAXFF2419 MAXFF1618 MAXFF1718 MAXFF1818 MAXFF1918 MAXFF2018 MAXFF2118 MAXFF2218 MAXFF2318 MAXFF2418 MAXFF1617 MAXFF1717 MAXFF1817 MAXFF1917 MAXFF2017 MAXFF2117 MAXFF2217 MAXFF2317 MAXFF2417 MAXFF1616 MAXFF1716 MAXFF1816 MAXFF1916 MAXFF2016 MAXFF2116 MAXFF2216 MAXFF2316 MAXFF2416 MAXFS1620 MAXFS1720 MAXFS1820 MAXFS1920 MAXFS2020 MAXFS2120 MAXFS2220 MAXFS2320 MAXFS2420 MAXFS1619 MAXFS1719 MAXFS1819 MAXFS1919 MAXFS2019 MAXFS2119 MAXFS2219 MAXFS2319 MAXFS2419 MAXFS1618 MAXFS1718 MAXFS1818 MAXFS1918 MAXFS2018 MAXFS2118 MAXFS2218 MAXFS2318 MAXFS2418 MAXFS1617 MAXFS1717 MAXFS1817 MAXFS1917 MAXFS2017 MAXFS2117 MAXFS2217 MAXFS2317 MAXFS2417 MAXFS1616 MAXFS1716 MAXFS1816 MAXFS1916 MAXFS2016 MAXFS2116 MAXFS2216 MAXFS2316 MAXFS2416 16” 16” 18” 18” 22” 22” 19” 19” 23” 23” 20” 20” 24” 24” 16” 16” 17” 17” 21” 21” 20” 20” 19” 19” 18” 18” 17” 17” COMFORT-TEK™ STRETCH-AIR™ $575.00 $384.00 $575.00 $384.00 $693.00 $462.00 $693.00 $462.00 Please select size in the appropriate fabric chart below. GlideWear ® cover options found on page 2. Company Name/ACCT #: P.O. Number: Requested By: Phone: Fax: Email: Ship To: Patient Reference: 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 Support at [email protected] or 800.736.0925 *DO NOT SEND PATIENT PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.* OR COMFORT-TEK™ FOR FLUID PROTECTION & AN EASILY CLEANED SURFACE. STRETCH-AIR™ FOR PATIENT COMFORT & HEAT DISSIPATION.
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MAX
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MAXX ORDER FORM Patient Reference: PAGE 1 of 6
*DO NOT SEND PATIENT PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*
SIZE & STYLE1
MAXX®
ORDER FORMHCPCS CODING: E2607/E2608SKIN PROTECTION & POSITIONING SEAT CUSHION
MAXX® shown with GlideWear®
DEP
THD
EPTH
WIDTH
WIDTH
MAXFF1620 MAXFF1720 MAXFF1820 MAXFF1920 MAXFF2020 MAXFF2120 MAXFF2220 MAXFF2320 MAXFF2420
MAXFF1619 MAXFF1719 MAXFF1819 MAXFF1919 MAXFF2019 MAXFF2119 MAXFF2219 MAXFF2319 MAXFF2419
MAXFF1618 MAXFF1718 MAXFF1818 MAXFF1918 MAXFF2018 MAXFF2118 MAXFF2218 MAXFF2318 MAXFF2418
MAXFF1617 MAXFF1717 MAXFF1817 MAXFF1917 MAXFF2017 MAXFF2117 MAXFF2217 MAXFF2317 MAXFF2417
MAXFF1616 MAXFF1716 MAXFF1816 MAXFF1916 MAXFF2016 MAXFF2116 MAXFF2216 MAXFF2316 MAXFF2416
MAXFS1620 MAXFS1720 MAXFS1820 MAXFS1920 MAXFS2020 MAXFS2120 MAXFS2220 MAXFS2320 MAXFS2420
MAXFS1619 MAXFS1719 MAXFS1819 MAXFS1919 MAXFS2019 MAXFS2119 MAXFS2219 MAXFS2319 MAXFS2419
MAXFS1618 MAXFS1718 MAXFS1818 MAXFS1918 MAXFS2018 MAXFS2118 MAXFS2218 MAXFS2318 MAXFS2418
MAXFS1617 MAXFS1717 MAXFS1817 MAXFS1917 MAXFS2017 MAXFS2117 MAXFS2217 MAXFS2317 MAXFS2417
MAXFS1616 MAXFS1716 MAXFS1816 MAXFS1916 MAXFS2016 MAXFS2116 MAXFS2216 MAXFS2316 MAXFS2416
16”
16”
18”
18”
22”
22”
19”
19”
23”
23”
20”
20”
24”
24”
16”
16”
17”
17”
21”
21”
20”
20”
19”
19”
18”
18”
17”
17”
COMFORT-TEK™
STRETCH-AIR™
$575.00$384.00
$575.00$384.00
$693.00$462.00
$693.00$462.00
Please select size in the appropriate fabric chart below.GlideWear® cover options found on page 2.
Company Name/ACCT #:
P.O. Number:
Requested By:
Phone: Fax:
Email:
Ship To:
Patient Reference:
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 Support at [email protected] or 800.736.0925 *DO NOT SEND PATIENT PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*
ORCOMFORT-TEK™
FOR FLUID PROTECTION & AN EASILY CLEANED SURFACE.
STRETCH-AIR™FOR PATIENT COMFORT
& HEAT DISSIPATION.
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MAXX ORDER FORM Patient Reference: PAGE 2 of 6
*DO NOT SEND PATIENT PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*
DEP
THD
EPTH
WIDTH
WIDTH
MAXFFQ1620 MAXFFQ1720 MAXFFQ1820 MAXFFQ1920 MAXFFQ2020 MAXFFQ2120 MAXFFQ2220 MAXFFQ2320 MAXFFQ2420
MAXFFQ1619 MAXFFQ1719 MAXFFQ1819 MAXFFQ1919 MAXFFQ2019 MAXFFQ2119 MAXFFQ2219 MAXFFQ2319 MAXFFQ2419
MAXFFQ1618 MAXFFQ1718 MAXFFQ1818 MAXFFQ1918 MAXFFQ2018 MAXFFQ2118 MAXFFQ2218 MAXFFQ2318 MAXFFQ2418
MAXFFQ1617 MAXFFQ1717 MAXFFQ1817 MAXFFQ1917 MAXFFQ2017 MAXFFQ2117 MAXFFQ2217 MAXFFQ2317 MAXFFQ2417
MAXFFQ1616 MAXFFQ1716 MAXFFQ1816 MAXFFQ1916 MAXFFQ2016 MAXFFQ2116 MAXFFQ2216 MAXFFQ2316 MAXFFQ2416
MAXFSQ1620 MAXFSQ1720 MAXFSQ1820 MAXFSQ1920 MAXFSQ2020 MAXFSQ2120 MAXFSQ2220 MAXFSQ2320 MAXFSQ2420
MAXFSQ1619 MAXFSQ1719 MAXFSQ1819 MAXFSQ1919 MAXFSQ2019 MAXFSQ2119 MAXFSQ2219 MAXFSQ2319 MAXFSQ2419
MAXFSQ1618 MAXFSQ1718 MAXFSQ1818 MAXFSQ1918 MAXFSQ2018 MAXFSQ2118 MAXFSQ2218 MAXFSQ2318 MAXFSQ2418
MAXFSQ1617 MAXFSQ1717 MAXFSQ1817 MAXFSQ1917 MAXFSQ2017 MAXFSQ2117 MAXFSQ2217 MAXFSQ2317 MAXFSQ2417
MAXFSQ1616 MAXFSQ1716 MAXFSQ1816 MAXFSQ1916 MAXFSQ2016 MAXFSQ2116 MAXFSQ2216 MAXFSQ2316 MAXFSQ2416
16”
16”
18”
18”
22”
22”
19”
19”
23”
23”
20”
20”
24”
24”
16”
16”
17”
17”
21”
21”
20”
20”
19”
19”
18”
18”
17”
17”
COMFORT-TEK™ with GLIDEWEAR®
STRETCH-AIR™ with GLIDEWEAR®
QUESTIONS? PLEASE CONTACT CUSTOMER SERVICE FOR ASSISTANCE. | 800.736.0925
$633.00$422.00
$633.00$422.00
$750.00$500.00
$750.00$500.00
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
MAXX® withPlease select size in the appropriate fabric chart below.
ORCOMFORT-TEK™
FOR FLUID PROTECTION & AN EASILY CLEANED SURFACE.
STRETCH-AIR™FOR PATIENT COMFORT
& HEAT DISSIPATION.
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MAXX ORDER FORM Patient Reference: PAGE 3 of 6
*DO NOT SEND PATIENT PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*
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)
One Incontinence Liner (INCON-LINER)
Two Incontinence Liners (INCON-LINER)
Red (RED) Blue (BLUE)
Purple (PURPLE) Green (GREEN)
Pink (PINK) Remove (REMOVE)
Orange (ORANGE)
B = 1” Rail Cut (RAIL-CUT-1.0)
B = 1½” Rail Cut (RAIL-CUT-1.5)
B = 2” Rail Cut (RAIL-CUT-2.0)
Solid Seat Pan & Hardware Kit(RSSP-N-HARD)
2.7REMOVABLE SOLID SEAT PAN & HARDWARE KITHCPCS Code: E2231 MSRP $387.00
Rigid Insert Glued(RGD-INSERT-GLUED)
Rigid Insert Not Glued(RGD-INSERT-UNGLUED)
2.8 RIGID INSERTHCPCS Code: E0992MSRP $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
C = 1” D (GROWTH-NOTCH-1)
C = 2” D (GROWTH-NOTCH-2)
C = 3” D (GROWTH-NOTCH-3)
C =Other(GROWTH-NOTCH-OTHER)
2.1 GROWTH NOTCHESMSRP $0.00
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
C
TOP VIEW
1¼”
2.5 INCONTINENCE LINERMSRP One = $60.00 - Two = $120.00
Liner provides extra incontinence protection for the cushion.
2.6 EXTRA COVERMSRP One = $62.00 - Two = $124.00
2.3COLOR - COMES STANDARD SILVER REFLECTIVE PIPINGMSRP $26.00
Accent colors can be applied to the cushion via colored piping. If no colors are selected, our standard silver reflective piping is used.
COLOR LOCATION
2.2 RAIL CUTSMSRP $26.00
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.
FRONT
B
1½”
Kwik Strap®
(KWIK-STRAP)
2.4 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
*All accessories are cosmetic changes to the cushion except for options in gray, which are add on items.MAXX® ACCESSORIES
ZIPPERED POUCHMSRP $26.00
2.9
Zippered Pouch (ZIP-POUCH)
ZIPPERED POUCH
LOCATION
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MAXX ORDER FORM Patient Reference: PAGE 4 of 6
*DO NOT SEND PATIENT PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*
BODILINK® LATERAL PELVIC/THIGH SUPPORT HARDWARE & PADS3
LD
AN
TI-T
HRU
ST
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 10”D BL-LPTSP1A-4L10D-LH BL-LPTSP1A-4L10D-LH BL-LPTSP1A-4L10D-RH BL-LPTSP1A-4L10D-RH
4”L x 12”D BL-LPTSP1A-4L12D-LH BL-LPTSP1A-4L12D-LH BL-LPTSP1A-4L12D-RH BL-LPTSP1A-4L12D-RH
4”L x 14”D BL-LPTSP1A-4L14D-LH BL-LPTSP1A-4L14D-LH BL-LPTSP1A-4L14D-RH BL-LPTSP1A-4L14D-RH
4”L x 16”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
STYLE SIZE LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT
ZERO
ELE
VATI
ON
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-RH4”L x 4”D BL-LPTSP1Z-4L4D-LH BL-LPTSP1Z-4L4D-LH BL-LPTSP1Z-4L4D-RH BL-LPTSP1Z-4L4D-RH4”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-RH4”L x 10”D BL-LPTSP1Z-4L10D-LH BL-LPTSP1Z-4L10D-LH BL-LPTSP1Z-4L10D-RH BL-LPTSP1Z-4L10D-RH4”L x 12” D BL-LPTSP1Z-4L12D-LH BL-LPTSP1Z-4L12D-LH BL-LPTSP1Z-4L12D-RH BL-LPTSP1Z-4L12D-RH4”L x 14” D BL-LPTSP1Z-4L14D-LH BL-LPTSP1Z-4L14D-LH BL-LPTSP1Z-4L14D-RH BL-LPTSP1Z-4L14D-RH
4”L x 16” 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
LD
Please select sizes in the appropriate fabric & style charts below. Contact Customer Support for custom sizes that are not listed below. 800.736.0925
OR
3.3 BASIC 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 3.3.• Follow each column down to section 3.3 and select a style and cover for each pad selected in
section 3.4.
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
3.4 BASIC PAD COVER
STYLE SIZE LEFT EXTRA LEFT RIGHT EXTRA RIGHT
3.5”L x 4”D BL-LPTSP2Z-3L4D-LH BL-LPTSP2Z-3L4D-LH BL-LPTSP2Z-3L4D-RH BL-LPTSP2Z-3L4D-RH
3.5”L x 8”D BL-LPTSP2Z-3L8D-LH BL-LPTSP2Z-3L8D-LH BL-LPTSP2Z-3L8D-RH BL-LPTSP2Z-3L8D-RH
3.5”L x 12”D BL-LPTSP2Z-3L12D-LH BL-LPTSP2Z-3L12D-LH BL-LPTSP2Z-3L12D-RH BL-LPTSP2Z-3L12D-RH
5.5”L x 6”D BL-LPTSP2Z-5L6D-LH BL-LPTSP2Z-5L6D-LH BL-LPTSP2Z-5L6D-RH BL-LPTSP2Z-5L6D-RH
3.1 PREMIUM PAD SIZE & SHAPEHCPCS Code: E0953 MSRP $62.00
*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 3.1 and select a style and cover for each pad selected in
section 3.2.
COVER OPTIONS MSRP LEFT EXTRA LEFT RIGHT EXTRA RIGHT
COMFORT-TEK™ $0.00/ea. LPTS-P2-COMFORT-FM LPTS-P2-COMFORT-FM LPTS-P2-COMFORT-FM LPTS-P2-COMFORT-FM
STRETCH-AIR™ $0.00/ea. LPTS-P2-STRETCH-FM LPTS-P2-STRETCH-FM LPTS-P2-STRETCH-FM LPTS-P2-STRETCH-FM
GLIDEWEAR® $13.00/ea. LPTS-P2-GLIDE-FM LPTS-P2-GLIDE-FM LPTS-P2-GLIDE-FM LPTS-P2-GLIDE-FM
FOR SKIN PROTECTION & SHEAR REDUCTION. NOT FLUID RESISTANT.
STRETCH-AIR™FOR PATIENT COMFORT &
HEAT DISSIPATION.
COMFORT-TEK™FOR FLUID PROTECTION & AN
EASILY CLEANED SURFACE.
3.2 PREMIUM PAD COVER WITH FOAM INSERT
L
D
FOR SKIN PROTECTION & SHEAR REDUCTION. NOT FLUID RESISTANT.
STRETCH-AIR™FOR PATIENT COMFORT &
HEAT DISSIPATION.
COMFORT-TEK™FOR FLUID PROTECTION & AN
EASILY CLEANED SURFACE.
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*DO NOT SEND PATIENT PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*
3.5
TT HARDWARE, SLOT MOUNT
A.
BODILINK® LATERAL PELVIC/THIGH SUPPORT HARDWARE
• You may make one selection per column (Left, Extra Left, Right, and Extra Right) in section 3.5 from group A, B, -OR- C.
• TT long extention arms (section 3.6) will only work with TT style hardware. • GT hardware extra links (section 3.6) will only work with GT style hardware.
SIZE MSRP LEFT EXTRA LEFT RIGHT EXTRA RIGHT
FIXE
D
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
REM
OVA
BLE
E102
8
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
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”
TT H
ARD
WAR
E SL
OT
MO
UN
T- F
IXED
TT H
ARD
WAR
E SL
OT
MO
UN
T-
REM
OVA
BLE
SMALL MEDIUM LARGE
HARDWARE SIZE VS. CUSHION THICKNESS
2.0”- 3.0”
3.0”- 4.5”
4.0”- 6.5”
TT H
ARD
WAR
E PO
WER
MO
UN
T- F
IXED
TT H
ARD
WAR
E PO
WER
MO
UN
T-
REM
OVA
BLE
SMALL MEDIUM LARGE
HARDWARE SIZE VS. CUSHION THICKNESS
2.0”- 3.5”
3.0”- 5.5”
4.0”- 7.5”
TT HARDWARE, POWER MOUNT B.HARDWARE SIZE
MAX 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
FIXE
D
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
REM
OVA
BLE
E102
8
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
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
OR
OR
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*DO NOT SEND PATIENT PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*
SUBMIT BY EMAIL
3.6 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 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
C.
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
GT
HAR
DW
ARE
SLO
T M
OU
NT-
FIX
ED
GT
HAR
DW
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SLO
T M
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RE
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VABL
E
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.
NO
MED
IAL
1” M
EDIA
L
BODILINK® MEDIAL KNEE/THIGH SUPPORT HARDWARE & PADS4
STYLE SIZE PART NUMBER
2.5”W x 3.5”D BL-MKTSP1-3W4D
3.5”W x 5”D BL-MKTSP1-4W5D
4”W x 6”D BL-MKTSP1-4W6D
2.5”W x 3.5”D BL-MKTSP2-3W4D
3.5”W x 5”D BL-MKTSP2-4W5D
5”W x 6”D BL-MKTSP2-5W6D
COMFORT-TEK FOR FLUID PROTECTION & AN EASILY CLEANED
SURFACE.
FOR PATIENT COMFORT& HEAT DISSIPATION.
STRETCH-AIR
FOR SKIN PROTECTION & SHEAR REDUCTION. NOT FLUID RESISTANT.
4.2 PAD COVER MATERIAL
GlideWear® (MKTSP-GLIDE) (add $15.00)
Comfort-Tek (MKTSP-COMFORT)
Stretch-Air (MKTSP-STRETCH)
PAD SIZE & SHAPE HCPCS CODING: E0957 MSRP $130.00
4.1
• You may make one selection per column.• Choose between wedge or oval in 4.1.• Choose a cover material in 4.2. • Choose hardware size in 4.3.
D
W
WEDGE
OVAL
W
4.3MEDIAL KNEE/THIGH SUPPORT SWING AWAY HARDWAREHCPCS CODING: E1028 MSRP $180.00
SIZE RECOMMENDED INFERIOR THIGH THICKNESS
Small 1.00”- 3.00”
Medium 2.00”- 5.00”
Large 3.00”- 7.00”
SIZE PART NUMBER
SMALL BL-MKTS-ST1SASL1
MEDIUM BL-MKTS-ST1SASL2
LARGE BL-MKTS-ST1SASL3SMALL MEDIUM LARGE
*Swing Away Hardware only, not available in Fixed Hardware**MKTS Hardware must be mounted to Removable Solid Seat
Pan in section 2.4***If Leg Length Discrepancy is needed on Removable Solid
Seat Pan, Offset Orientation must be selected
Inferior Thigh Thickness
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