HYALITE ORDER FORMd37xlajmpyyml6.cloudfront.net/standard_order_forms/Hyalite Order 0… · 2.6 EXTRA COVER MSRP One = $62.00 - Two = $124.00 2.3 COLOR - COMES STANDARD SILVER REFLECTIVE

HYA

LITE

-ORD

ER R

EV02

1319

HYALITE ORDER FORM Patient Reference: PAGE 1 of 5

*DO NOT SEND PATIENT PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*

SIZE & COVER1

HYALITE®

ORDER FORMHCPCS CODING: E2603/E2604 SKIN PROTECTION SEAT CUSHION

Hyalite

DEP

THD

EPTH

WIDTH

WIDTH

HY-GF-1620 HY-GF-1720 HY-GF-1820 HY-GF-1920 HY-GF-2020 HY-GF-2120 HY-GF-2220 HY-GF-2320 HY-GF-2420





HY-GU-1620 HY-GU-1720 HY-GU-1820 HY-GU-1920 HY-GU-2020 HY-GU-2120 HY-GU-2220 HY-GU-2320 HY-GU-2420





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™

$367.00$245.00

$367.00$245.00

$478.00$319.00

$478.00$319.00

Please select size in the appropriate fabric chart below.

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 1.406.522.8563. *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.

HYA

LITE

-ORD

ER R

EV02

1319



Red (RED) Blue (BLUE)

Purple (PURPLE) Green (GREEN)

Pink (PINK) Remove (REMOVE)

Orange (ORANGE)

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)

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 =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.HYALITE® ACCESSORIES

HYA

LITE

-ORD

ER R

EV02

1319



BODILINK® LATERAL PELVIC/THIGH SUPPORT HARDWARE & PADS3 Please select sizes in the appropriate fabric &

style charts below. Contact Customer Support for custom sizes that are not listed below 800.736.0925.

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




3.1 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.• Make a fabric selection in 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

3.3

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 3.3 from group A, B, -OR- C.

• TT long extention arms (section 3.4) will only work with TT 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”

OR

HYA

LITE

-ORD

ER R

EV02

1319



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

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

LEFT EXTRA LEFT RIGHT EXTRA RIGHT

BL-LPTS-TT1LARM4 BL-LPTS-TT1LARM4 BL-LPTS-TT1LARM4 BL-LPTS-TT1LARM4

3.4 TT LONG EXTENSION ARM 4” MSRP $37.00/arm

HYA

LITE

-ORD

ER R

EV02

1319



SUBMIT BY EMAIL

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

Documents

HYALITE ORDER FORMd37xlajmpyyml6.cloudfront.net/standard_order_forms/Hyalite Order 0… · 2.6 EXTRA COVER MSRP One = $62.00 - Two = $124.00 2.3 COLOR - COMES STANDARD SILVER REFLECTIVE