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LIBERTY X 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.*

$477.00

$515.00

$477.00

$515.00

SIZE & STYLE1

LIBERTY® X ORDER FORMHCPCS CODING: E2622ADJUSTABLE SKIN PROTECTION

Liberty® X shown with GlideWear® Liberty® X Liner and Foam Base

DEP

THD

EPTH

DEP

THD

EPTH

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®

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

QUESTIONS? PLEASE CONTACT CUSTOMER SERVICE FOR ASSISTANCE. | 800.736.0925 Liberty® X is not recommended for use in altitudes above 3,000 ft.

ORCOMFORT-TEK™

FOR FLUID PROTECTION & AN EASILY CLEANED SURFACE.

STRETCH-AIR™FOR PATIENT COMFORT

& HEAT DISSIPATION.

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 orders.comfort@permobil.com or 1.406.522.8563. *DO NOT SEND PATIENT PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*

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LIBERTY X ORDER FORM Patient Reference: PAGE 2 of 5

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

One Incontinence Liner (INCON-LINER)

Two Incontinence Liners (INCON-LINER)

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)

(fits) 16W x 16D -OR- 16W x 18D (PS-1618)

(fits) 18W x 16D -OR- 18W x 18D (PS-1818)

Red (RED) Silver Reflective (SILVER)

Purple (PURPLE) Green (GREEN)

Pink (PINK) Remove (REMOVE)

Orange (ORANGE)

2 *All accessories are cosmetic changes to the cushion except for options in gray, which are add on items.

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.

2.4

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

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

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LIBERTY X ORDER FORM Patient Reference: PAGE 3 of 5

*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 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

3.5”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.• 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

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LIBERTY X ORDER FORM Patient Reference: PAGE 4 of 5

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

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

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LIBERTY X ORDER FORM Patient Reference: PAGE 5 of 5

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

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