COMFORT-TEK AC-GF-1620 AC-GF-1720 AC-GF-1820 AC-GF-1920 AC-GF-2020 AC-GF-2120 AC-GF-2220 AC-GF-2320 AC-GF-2420
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- Hannah Shelton
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1 ASCENT ER FM HCPCS COING: E2603/E2604 SKIN PROTECTION SEAT Ascent Company Name/ACCT #: P.O. Number: Requested By: Phone: Ship To: Patient Reference: Fax: 1 SIZE & COVER 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 Support at orders.comfort@permobil.com or *O NOT SEN PATIENT PROTECTE HEATH INFMATION. IT IS NOT NEEE TO MAKE THE PROUCT YOU ARE REQUESTING.* Please select size in the appropriate fabric chart below. F FUI PROTECTION & AN EASIY CEANE SURFACE. F PATIENT COMFT & HEAT ISSIPATION. $ $ $ $ AC-GF-1620 AC-GF-1720 AC-GF-1820 AC-GF-1920 AC-GF-2020 AC-GF-2120 AC-GF-2220 AC-GF-2320 AC-GF-2420 EPTH AC-GF-1619 AC-GF-1719 AC-GF-1819 AC-GF-1919 AC-GF-2019 AC-GF-2119 AC-GF-2219 AC-GF-2319 AC-GF-2419 AC-GF-1618 AC-GF-1718 AC-GF-1818 AC-GF-1918 AC-GF-2018 AC-GF-2118 AC-GF-2218 AC-GF-2318 AC-GF-2418 AC-GF-1617 AC-GF-1717 AC-GF-1817 AC-GF-1917 AC-GF-2017 AC-GF-2117 AC-GF-2217 AC-GF-2317 AC-GF-2417 AC-GF-1616 AC-GF-1716 AC-GF-1816 AC-GF-1916 AC-GF-2016 AC-GF-2116 AC-GF-2216 AC-GF-2316 AC-GF WITH $ $ $ $ AC-GS-1620 AC-GS-1720 AC-GS-1820 AC-GS-1920 AC-GS-2020 AC-GS-2120 AC-GS-2220 AC-GS-2320 AC-GS-2420 EPTH AC-GS-1619 AC-GS-1719 AC-GS-1819 AC-GS-1919 AC-GS-2019 AC-GS-2119 AC-GS-2219 AC-GS-2319 AC-GS-2419 AC-GS-1618 AC-GS-1718 AC-GS-1818 AC-GS-1918 AC-GS-2018 AC-GS-2118 AC-GS-2218 AC-GS-2318 AC-GS-2418 AC-GS-1617 AC-GS-1717 AC-GS-1817 AC-GS-1917 AC-GS-2017 AC-GS-2117 AC-GS-2217 AC-GS-2317 AC-GS-2417 AC-GS-1616 AC-GS-1716 AC-GS-1816 AC-GS-1916 AC-GS-2016 AC-GS-2116 AC-GS-2216 AC-GS-2316 AC-GS WITH ASCENT-ER REV1018 ASCENT ER FM Patient Reference: PAGE 1 of 5 *O NOT SEN PATIENT PROTECTE HEATH INFMATION. IT IS NOT NEEE TO MAKE THE PROUCT YOU ARE REQUESTING.*
2 2 ASCENT ACCESSIES *All accessories are cosmetic changes to the cushion except for options in gray, which are add on items. 2.1 GROWTH NOTCHES MSRP $ RAI CUTS MSRP $ CO - COMES STANAR SIVER REFECTIVE 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. EPTH 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 CO OCATION C = 1 (GROWTH-NOTCH-1) B = 1 Rail Cut (RAI-CUT-1.0) Red (RE) Blue (BUE) C = 2 (GROWTH-NOTCH-2) B = 1½ Rail Cut (RAI-CUT-1.5) Purple (PURPE) Green (GREEN) C = 3 (GROWTH-NOTCH-3) B = 2 Rail Cut (RAI-CUT-2.0) Pink (PINK) Remove (REMOVE) C =Other (GROWTH-NOTCH-OTHER) Orange (ANGE) 2.4 KWIK STRAP MSRP $ INCONTINENCE INER 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. iner provides extra incontinence protection for the cushion. Rear View Kwik Strap (KWIK-STRAP) One Extra Incontinence iner (INCON-INER) Two Extra Incontinence iners (INCON-INER) 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 REMOVABE SOI SEAT PAN & HARWARE KIT HCPCS Code: E2231 MSRP $ RIGI 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. ateral thigh support hardware can be easily attached. 3/16 Plastic rigidizing board. ASCENT-ER REV1018 Solid Seat Pan & Hardware Kit (RSSP-N-HAR) Rigid Insert Glued (RG-INSERT-GUE) Rigid Insert Not Glued (RG-INSERT-UNGUE) ASCENT ER FM Patient Reference: PAGE 2 of 5 *O NOT SEN PATIENT PROTECTE HEATH INFMATION. IT IS NOT NEEE TO MAKE THE PROUCT YOU ARE REQUESTING.*
3 3 BOIINK ATERA PEVIC/THIGH SUPPT HARWARE & PAS Please select sizes in the appropriate fabric & style charts below. Contact Customer Support for custom sizes that are not listed below PREMIUM PA SIZE & SHAPE HCPCS Code: E0953 MSRP $62.00 You may make one selection per column (eft, Extra eft, 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. *ength () refers to the actual size dimension of the support from top to bottom edge. epth () refers to the actual size dimension from anterior to posterior edge. STYE SIZE EFT EXTRA EFT RIGHT EXTRA RIGHT 3.5 x 4 B-PTSP2Z-34-H B-PTSP2Z-34-H B-PTSP2Z-34-RH B-PTSP2Z-34-RH 3.5 x 8 B-PTSP2Z-38-H B-PTSP2Z-38-H B-PTSP2Z-38-RH B-PTSP2Z-38-RH 3.5 x 12 B-PTSP2Z-312-H B-PTSP2Z-312-H B-PTSP2Z-312-RH B-PTSP2Z-312-RH 5.5 x 6 B-PTSP2Z-56-H B-PTSP2Z-56-H B-PTSP2Z-56-RH B-PTSP2Z-56-RH 3.2 PREMIUM PA COVER WITH FOAM INSERT COVER OPTIONS MSRP EFT EXTRA EFT RIGHT EXTRA RIGHT $0.00/ea. PTS-P2-COMFT-FM PTS-P2-COMFT-FM PTS-P2-COMFT-FM PTS-P2-COMFT-FM $0.00/ea. PTS-P2-STRETCH-FM PTS-P2-STRETCH-FM PTS-P2-STRETCH-FM PTS-P2-STRETCH-FM GIEWEAR $13.00/ea. PTS-P2-GIE-FM PTS-P2-GIE-FM PTS-P2-GIE-FM PTS-P2-GIE-FM F FUI PROTECTION & AN EASIY CEANE SURFACE. F PATIENT COMFT & HEAT ISSIPATION. F SKIN PROTECTION & SHEAR REUCTION. NOT FUI RESISTANT. 3.3 BASIC PA SIZE & SHAPE HCPCS Code: E0953 MSRP $52.00 You may make one selection per column (eft, Extra eft, 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. *ength () refers to the actual size dimension of the support from top to bottom edge. epth () refers to the actual size dimension from anterior to posterior edge. ZERO EEVATION ANTI-THRUST 3.4 BASIC PA COVER STYE SIZE EFT *EXTRA EFT RIGHT *EXTRA RIGHT 3 x 4 B-PTSP1Z-34-H B-PTSP1Z-34-H B-PTSP1Z-34-RH B-PTSP1Z-34-RH 3 x 5 B-PTSP1Z-35-H B-PTSP1Z-35-H B-PTSP1Z-35-RH B-PTSP1Z-35-RH 4 x 4 B-PTSP1Z-44-H B-PTSP1Z-44-H B-PTSP1Z-44-RH B-PTSP1Z-44-RH 4 x 6 B-PTSP1Z-46-H B-PTSP1Z-46-H B-PTSP1Z-46-RH B-PTSP1Z-46-RH 4 x 8 B-PTSP1Z-48-H B-PTSP1Z-48-H B-PTSP1Z-48-RH B-PTSP1Z-48-RH 4 x 10 B-PTSP1Z-410-H B-PTSP1Z-410-H B-PTSP1Z-410-RH B-PTSP1Z-410-RH 4 x 12 B-PTSP1Z-412-H B-PTSP1Z-412-H B-PTSP1Z-412-RH B-PTSP1Z-412-RH 4 x 14 B-PTSP1Z-414-H B-PTSP1Z-414-H B-PTSP1Z-414-RH B-PTSP1Z-414-RH 4 x 16 B-PTSP1Z-416-H B-PTSP1Z-416-H B-PTSP1Z-416-RH B-PTSP1Z-416-RH 5 x 7 B-PTSP1Z-57-H B-PTSP1Z-57-H B-PTSP1Z-57-RH B-PTSP1Z-57-RH 3 x 4 B-PTSP1A-34-H B-PTSP1A-34-H B-PTSP1A-34-RH B-PTSP1A-34-RH 3 x 5 B-PTSP1A-35-H B-PTSP1A-35-H B-PTSP1A-35-RH B-PTSP1A-35-RH 4 x 4 B-PTSP1A-44-H B-PTSP1A-44-H B-PTSP1A-44-RH B-PTSP1A-44-RH 4 x 6 B-PTSP1A-46-H B-PTSP1A-46-H B-PTSP1A-46-RH B-PTSP1A-46-RH 4 x 8 B-PTSP1A-48-H B-PTSP1A-48-H B-PTSP1A-48-RH B-PTSP1A-48-RH 4 x 10 B-PTSP1A-410-H B-PTSP1A-410-H B-PTSP1A-410-RH B-PTSP1A-410-RH 4 x 12 B-PTSP1A-412-H B-PTSP1A-412-H B-PTSP1A-412-RH B-PTSP1A-412-RH 4 x 14 B-PTSP1A-414-H B-PTSP1A-414-H B-PTSP1A-414-RH B-PTSP1A-414-RH 4 x 16 B-PTSP1A-416-H B-PTSP1A-416-H B-PTSP1A-416-RH B-PTSP1A-416-RH 5 x 7 B-PTSP1A-57-H B-PTSP1A-57-H B-PTSP1A-57-RH B-PTSP1A-57-RH F FUI PROTECTION & AN EASIY CEANE SURFACE. F PATIENT COMFT & HEAT ISSIPATION. COVER OPTIONS MSRP EFT *EXTRA EFT RIGHT *EXTRA RIGHT F SKIN PROTECTION & SHEAR REUCTION. NOT FUI RESISTANT. ASCENT-ER REV1018 $0.00/ea. PTS-P1-COMFT PTS-P1-COMFT PTS-P1-COMFT PTS-P1-COMFT $0.00/ea. PTS-P1-STRETCH PTS-P1-STRETCH PTS-P1-STRETCH PTS-P1-STRETCH GIEWEAR $13.00/ea. PTS-P1-GIE PTS-P1-GIE PTS-P1-GIE PTS-P1-GIE ASCENT ER FM Patient Reference: PAGE 3 of 5 *O NOT SEN PATIENT PROTECTE HEATH INFMATION. IT IS NOT NEEE TO MAKE THE PROUCT YOU ARE REQUESTING.*
4 3.5 A. BOIINK ATERA PEVIC/ THIGH SUPPT HARWARE TT HARWARE, SOT MOUNT TT HARWARE SOT MOUNT- FIXE TT HARWARE SOT MOUNT- REMOVABE You may make one selection per column (eft, Extra eft, Right, and Extra Right) in section 3.5 from group A, B, -- 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. HARWARE SIZE VS SMA MEIUM ARGE HARWARE SIZE CEARANCE RECOMMENE SMA MEIUM ARGE SIZE MSRP EFT EXTRA EFT RIGHT EXTRA RIGHT SMA $ B-PTS-TT1FXS1-H B-PTS-TT1FXS1-H B-PTS-TT1FXS1-RH B-PTS-TT1FXS1-RH FIXE MEIUM $ B-PTS-TT1FXS2-H B-PTS-TT1FXS2-H B-PTS-TT1FXS2-RH B-PTS-TT1FXS2-RH ARGE $ B-PTS-TT1FXS3-H B-PTS-TT1FXS3-H B-PTS-TT1FXS3-RH B-PTS-TT1FXS3-RH REMOVABE SMA $ B-PTS-TT1RMS1-H B-PTS-TT1RMS1-H B-PTS-TT1RMS1-RH B-PTS-TT1RMS1-RH MEIUM $ B-PTS-TT1RMS2-H B-PTS-TT1RMS2-H B-PTS-TT1RMS2-RH B-PTS-TT1RMS2-RH ARGE $ B-PTS-TT1RMS3-H B-PTS-TT1RMS3-H B-PTS-TT1RMS3-RH B-PTS-TT1RMS3-RH B. TT HARWARE, POWER MOUNT HARWARE SIZE VS. TT HARWARE POWER MOUNT- FIXE TT HARWARE POWER MOUNT- REMOVABE HARWARE SIZE CEARANCE RECOMMENE SMA MEIUM ARGE SMA MEIUM ARGE SIZE MSRP EFT EXTRA EFT RIGHT EXTRA RIGHT SMA $ B-PTS-TT1FXPW1-H B-PTS-TT1FXPW1-H B-PTS-TT1FXPW1-RH B-PTS-TT1FXPW1-RH FIXE MEIUM $ B-PTS-TT1FXPW2-H B-PTS-TT1FXPW2-H B-PTS-TT1FXPW2-RH B-PTS-TT1FXPW2-RH ARGE $ B-PTS-TT1FXPW3-H B-PTS-TT1FXPW3-H B-PTS-TT1FXPW3-RH B-PTS-TT1FXPW3-RH REMOVABE SMA $ B-PTS-TT1RMPW1-H B-PTS-TT1RMPW1-H B-PTS-TT1RMPW1-RH B-PTS-TT1RMPW1-RH MEIUM $ B-PTS-TT1RMPW2-H B-PTS-TT1RMPW2-H B-PTS-TT1RMPW2-RH B-PTS-TT1RMPW2-RH ARGE $ B-PTS-TT1RMPW3-H B-PTS-TT1RMPW3-H B-PTS-TT1RMPW3-RH B-PTS-TT1RMPW3-RH TT HARWARE, 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 PTS-TT1-PW1 PERMOBI add $0.00 PTS-TT1-PW2 QUICKIE add $0.00 PTS-TT1-PW3 ASCENT-ER REV1018 ROVI add $0.00 PTS-TT1-PW4 AVI REHAB add $0.00 PTS-TT1-PW5 ASCENT ER FM Patient Reference: PAGE 4 of 5 *O NOT SEN PATIENT PROTECTE HEATH INFMATION. IT IS NOT NEEE TO MAKE THE PROUCT YOU ARE REQUESTING.*
5 C. GT HARWARE (ONY SOT MOUNT) GT HARWARE SOT MOUNT- FIXE GT HARWARE SOT MOUNT- REMOVABE NO MEIA 1 MEIA HARWARE CEARANCE RECOMMENE NO MEIA * MEIA * *If you need to increase the height or medial reach, add additional links in section 2.2. SIZE MSRP EFT EXTRA EFT RIGHT EXTRA RIGHT FIXE $ B-PTS-GT2FXS-H B-PTS-GT2FXS-H B-PTS-GT2FXS-RH B-PTS-GT2FXS-RH REMOVABE $ B-PTS-GT2RMS-H B-PTS-GT2RMS-H B-PTS-GT2RMS-RH B-PTS-GT2RMS-RH 3.6 AITIONA OPTIONS TT ONG EXTENSION ARM 4 EFT EXTRA EFT RIGHT EXTRA RIGHT MSRP $37.00/arm B-PTS-TT1ARM4 B-PTS-TT1ARM4 B-PTS-TT1ARM4 B-PTS-TT1ARM4 GT AITIONA HARWARE INKS ASCENT-ER REV1018 MSRP $37.00/link (2 Additional 1.25 inks Allowed Per Hardware Ordered) EFT EXTRA EFT RIGHT EXTRA RIGHT B-PTS-GT2INK B-PTS-GT2INK B-PTS-GT2INK B-PTS-GT2INK B-PTS-GT2INK B-PTS-GT2INK B-PTS-GT2INK B-PTS-GT2INK ASCENT ER FM Patient Reference: SUBMIT BY EMAI PAGE 5 of 5 *O NOT SEN PATIENT PROTECTE HEATH INFMATION. IT IS NOT NEEE TO MAKE THE PROUCT YOU ARE REQUESTING.*
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