$477.00
$515.00
$477.00
$515.00
SIZE & STYLE1
LIBERTY® X ORDER FORMHCPCS CODING: E2622ADJUSTABLE SKIN PROTECTION
Company Name/ACCT #:
P.O. Number:
Requested By:
Phone: Fax:
Email:
Ship To:
Patient Reference:
Liberty® X shown with GlideWear® Liberty® X Liner and Foam Base
LIB
ER
TY-X
-OR
DE
R R
EV
0418
DE
PTH
DE
PTH
DE
PTH
DE
PTH
WIDTH
WIDTH
WIDTH
WIDTH
LBX-F-1820 LBX-F-2020
LBX-F-1618 LBX-F-1818 LBX-F-2018
LBX-F-1717
LBX-F-1616 LBX-F-1816
LBX-FQ-1820 LBX-FQ-2020
LBX-FQ-1618 LBX-FQ-1818 LBX-FQ-2018
LBX-FQ-1717
LBX-FQ-1616 LBX-FQ-1816
LBX-S-1820 LBX-S-2020
LBX-S-1618 LBX-S-1818 LBX-S-2018
LBX-S-1717
LBX-S-1616 LBX-S-1816
LBX-SQ-1820 LBX-SQ-2020
LBX-SQ-1618 LBX-SQ-1818 LBX-SQ-2018
LBX-SQ-1717
LBX-SQ-1616 LBX-SQ-1816
16”
16”
16”
16”
18”
18”
18”
18”
19”
19”
19”
19”
20”
20”
20”
20”
16”
16”
16”
16”
17”
17”
17”
17”
20”
20”
20”
20”
19”
19”
19”
19”
18”
18”
18”
18”
17”
17”
17”
17”
COMFORT-TEK™
COMFORT-TEK™ with GLIDEWEAR®
STRETCH-AIR™
STRETCH-AIR™ with GLIDEWEAR®
LIBERTY® X ORDER FORM Patient Reference: PAGE 1 of 4
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.
Please select size in the appropriate fabric chart below.
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
SELECTED FOR AIR TRANSMISSION & HEAT DISSIPATION.
STRETCH-AIR™ SELECTED FOR INCONTINENCE PROTECTION
& AN EASILY CLEANED SURFACE.
COMFORT-TEK™OR
QUESTIONS? PLEASE CONTACT CUSTOMER SERVICE FOR ASSISTANCE. | 800.564.9248
Liberty® X is not recommended for use in altitudes above 3,000 ft.
Red (RED) Silver Reflective (SILVER)
Purple (PURPLE) Green (GREEN)
Pink (PINK) Remove (REMOVE)
Orange (ORANGE)
LIBERTY® X ORDER FORM Patient Reference: PAGE 2 of 4
2 *All accessories are cosmetic changes to the cushion except for options in gray, which are add on items.
LIB
ER
TY-X
-OR
DE
R R
EV
0418
LIBERTY® X ACCESSORIES
Solid Seat Pan & Hardware Kit(RSSP-N-HARD)
2.5REMOVABLE SOLID SEAT PAN & HARDWARE KITHCPCS Code: E2231 MSRP $387.00
Rigid Insert Not Glued(RGD-INSERT-UNGLUED)
2.6 RIGID INSERTHCPCS 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.
3/16” Plastic rigidizing board.
2.3
Liner provides extra incontinence protection for the cushion.
One Extra Incontinence Liner (INCON-LINER)
Two Extra Incontinence Liners (INCON-LINER)
2.4
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)
Kwik Strap®
(KWIK-STRAP)
2.2 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
2.7 VICAIR® PELVIC STABILIZER MSRP $118.00
(fits) 16W x 16D -OR- 16W x 18D (PS-1618)
(fits) 18W x 16D -OR- 18W x 18D (PS-1818)
2.1COLOR - COMES STANDARD W/ REFLECTIVE BLUE PIPINGMSRP $26.00
Accent colors can be applied to the cushion via colored piping. If no colors are selected, our standard reflective blue piping is used.
COLOR LOCATION
INCONTINENCE LINERMSRP One = $60.00 - Two = $120.00
EXTRA COVERMSRP One = $62.00 - Two = $124.00
LIB
ER
TY-X
-OR
DE
R R
EV
0418
LIBERTY® X ORDER FORM Patient Reference: PAGE 3 of 4
BODILINK® LATERAL PELVIC/THIGH SUPPORT HARDWARE & PADS3
LD
AN
TI-T
HR
UST
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
ZE
RO
ELE
VA
TIO
N
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 10”D BL-LPTSP1Z-4L10D-LH BL-LPTSP1Z-4L10D-LH BL-LPTSP1Z-4L10D-RH BL-LPTSP1Z-4L10D-RH
4”L x 12” D BL-LPTSP1Z-4L12D-LH BL-LPTSP1Z-4L12D-LH BL-LPTSP1Z-4L12D-RH BL-LPTSP1Z-4L12D-RH
4”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. 1.800.564.9248.
OR
3.1BASIC 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 3.1.• Follow each column down to section 3.2 and select a style and cover for each pad selected in section 3.1.
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
FOR SKIN PROTECTION & SHEAR REDUCTION. NOT FLUID RESISTANT.
STRETCH-AIR™FOR AIR TRANSMISSION
& HEAT DISSIPATION.
COMFORT-TEK™FOR FLUID PROTECTION & AN
EASILY CLEANED SURFACE.
3.2 BASIC PAD COVER
3.3
TT HARDWARE, SLOT MOUNT
A.
BODILINK® LATERAL PELVIC/THIGH SUPPORT HARDWARE
SIZE MSRP LEFT *EXTRA LEFT RIGHT * EXTRA RIGHT
FIX
ED
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
RE
MO
VA
BLE
E10
28
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
OR
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
HA
RD
WA
RE
S
LO
T M
OU
NT
- F
IXE
D
TT
HA
RD
WA
RE
S
LO
T M
OU
NT
- R
EM
OV
AB
LE
SMALL MEDIUM LARGE
HARDWARE SIZE V. CUSHION THICKNESS
2.0”- 3.0”
3.0”- 4.5”
4.0”- 6.5”
• 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. • GT hardware extra links (section 3.4) will only work with GT style hardware.
LIB
ER
TY-X
-OR
DE
R R
EV
0418
LIBERTY® X ORDER FORM Patient Reference: PAGE 4 of 4
TT
HA
RD
WA
RE
P
OW
ER
MO
UN
T-
FIX
ED
TT
HA
RD
WA
RE
P
OW
ER
MO
UN
T-
RE
MO
VA
BL
E
SMALL MEDIUM LARGE
HARDWARE SIZE V. CUSHION THICKNESS
2.0”- 3.5”
3.0”- 5.5”
4.0”- 7.5”TT HARDWARE, POWER MOUNT B.
HARDWARE SIZEMAX 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
FIX
ED
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
RE
MO
VA
BLE
E10
28
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
OR
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
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
HA
RD
WA
RE
S
LO
T M
OU
NT
- F
IXE
D
GT
HA
RD
WA
RE
S
LO
T M
OU
NT
- R
EM
OV
AB
LE
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
ME
DIA
L
1” M
ED
IAL
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
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
SUBMIT BY EMAIL