Comfort M2 Cushion Order Form

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Comfort M2 CushionOrder FormHCPCS CODING: E2607/E2608SKIN PROTECTION & POSITIONING SEAT CUSHIONCompany Name/ACCT #:P.O. Number:M2 shown with GlideWear M2 Zero ElevationRequested By:Phone:Fax:Email:Ship To:Client Reference:For best results, do not fill out in your browser. Interactive formshould be completed using Adobe Reader after saving to yourlocal drive. Then email or print and fax to Customer Support atorders.comfort@permobil.com or 1.406.522.8563.1*DO NOT SEND PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THEPRODUCT YOU ARE REQUESTING.*SIZE & STYLECOMFORT-TEK FOR FLUID PROTECTION &AN EASILY CLEANED SURFACE.ZERO ELEVATIONSTRETCH-AIR ORFOR COMFORT& HEAT DISSIPATION.Please select size in the appropriate fabric chart below.COMFORT-TEK -162221”20”M2-F-142019”DEPTH THSTRETCH-AIR TH 9”20”21”22”23”24”WIDTHM2 ORDER FORMClient Reference:*DO NOT SEND PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*PAGE 1 of 10

GLIDEWEAR is designed to promote healing as well as reduce the risk of skin breakdown. A GlideWear Shear Reduction Panel isincorporated into the cover under the most at-risk areas to allow for micro-movements without the deformation of tissue.COMFORT-TEKSTRETCH-AIRORFOR FLUID PROTECTION &AN EASILY CLEANED SURFACE.FOR COMFORT& HEAT DISSIPATION.ZERO ELEVATION withPlease select size in the appropriate fabric chart below.COMFORT-TEK with GLIDEWEAR 322”21”DEPTH �23”24”WIDTHSTRETCH-AIR with GLIDEWEAR �DEPTH �21”22”23”24”WIDTHQUESTIONS? PLEASE CONTACT CUSTOMER SUPPORT FOR ASSISTANCE. 800.736.0925M2 ORDER FORMClient Reference:*DO NOT SEND PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*PAGE 2 of 10

COMFORT-TEKSTRETCH-AIRORFOR FLUID PROTECTION &AN EASILY CLEANED SURFACE.FOR COMFORT& HEAT DISSIPATION.ANTI-THRUSTPlease select size in the appropriate fabric chart below.COMFORT-TEK �DEPTH �21”22”23”24”WIDTHSTRETCH-AIR 322”21”DEPTH �23”24”WIDTHQUESTIONS? PLEASE CONTACT CUSTOMER SUPPORT FOR ASSISTANCE. 800.736.0925M2 ORDER FORMClient Reference:*DO NOT SEND PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*PAGE 3 of 10

GLIDEWEAR is designed to promote healing as well as reduce the risk of skin breakdown.A GlideWear Shear Reduction Panel isincorporated into the cover under the most at-risk areas to allow for micro-movements without the deformation of tissue.COMFORT-TEKFOR FLUID PROTECTION &AN EASILY CLEANED SURFACE.STRETCH-AIRORFOR COMFORT& HEAT DISSIPATION.ANTI-THRUST withPlease select size in the appropriate fabric chart below.COMFORT-TEK with GLIDEWEAR 2323M2-FQA-242322”21”DEPTH RETCH-AIR with GLIDEWEAR ��20”M2-SQA-142019”DEPTH QUESTIONS? PLEASE CONTACT CUSTOMER SUPPORT FOR ASSISTANCE. 800.736.0925M2 ORDER FORMClient Reference:*DO NOT SEND PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*PAGE 4 of 10

2M2 ACCESSORIES2.1 GROWTH NOTCHES2.2 RAIL CUTSMSRP 0.002.3 COLORMSRP 26.00If growth notches are selected, a 1¼” wide cut willbe taken from each side to allow the cushion to fitbetween the chair canes.MSRP 26.00A standard 1 1/2” wide cut will be made and youdecide how high the cut will need to be. All cutsrun the entire depth of the cushion.DEPTH OF NOTCHES1¼”Accent colors can be applied to the cushion viacolored piping. If no colors are selected, ourstandard silver reflective piping is used at noadditional cost.CBTOPVIEW1½”COLOR LOCATIONFRONTC 1” D (GROWTH-NOTCH-1)B 1” Rail Cut (RAIL-CUT-1.0)C 2” D (GROWTH-NOTCH-2)B 1½” Rail Cut (RAIL-CUT-1.5)B 2” Rail Cut (RAIL-CUT-2.0)Red (RED)Blue (BLUE)Purple (PURPLE)Green (GREEN)Pink (PINK)Remove (REMOVE)Orange (ORANGE)2.4 INCONTINENCE LINER2.5 EXTRA COVERMSRP 60.00 EachMSRP 90.00 eachLiner provides extra incontinence protectionfor the cushion.M2- - W MFORT-TEK)QuantitySTRETCH-AIR with GlidewearIncontinence Liner (BINC-M2 - W D)(GW-STRETCH-AIR)COMFORT-TEK with Glidewear(GW-COMFORT-TEK)REMOVABLE SOLID SEATPAN & HARDWARE KITHCPCS Code: E2231RIGID INSERT2.7 HCPCSCode: E0992MSRP 65.00MSRP 387.00The solid seat pan kit includes a slotted aluminum panand attaching hardware to accommodate 7/8” or 1”tubing. The kit also comes with two different cross bars toaccommodate various wheelchair frame types. This will fitboth folding and non-folding seat rails. Lateral thigh supporthardware can be easily attached.3/16” Plastic rigidizing board.M2-ORDER REV1203202.6Rigid Insert Glued(RID )Solid Seat Pan & Hardware KitRigid Insert Not Glued(RSSP-1- )M2 ORDER FORM(RID )Client Reference:*DO NOT SEND PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*PAGE 5 of 8

3BODILINK LATERAL PELVIC/THIGHSUPPORT HARDWARE & PADSPREMIUM PAD SIZE & SHAPE3.1HCPCS Code: E0953Please select sizes in the appropriate fabric &style charts below. Contact Customer Supportfor custom sizes that are not listed below800.736.0925. 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.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.STYLESIZELDLEFTEXTRA LEFTRIGHTEXTRA RIGHT3.5”L x Z-3L4D-RHBL-LPTSP2Z-3L4D-RH3.5”L x Z-3L8D-RHBL-LPTSP2Z-3L8D-RH3.5”L x SP2Z-3L12D-RHBL-LPTSP2Z-3L12D-RH5.5”L x Z-5L6D-RHBL-LPTSP2Z-5L6D-RHPREMIUM PAD COVER3.2WITH FOAM INSERTLEFTEXTRA LEFTRIGHTEXTRA RIGHTCOVER OPTIONSMSRPCOMFORT-TEK 2-COMFORT-FMLPTS-P2-COMFORT-FMSTRETCH-AIR 2-STRETCH-FMLPTS-P2-STRETCH-FMGLIDEWEAR LIDE-FMLPTS-P2-GLIDE-FMSTRETCH-AIRCOMFORT-TEKFOR FLUID PROTECTION & ANEASILY CLEANED SURFACE.FOR SKIN PROTECTION& SHEAR REDUCTION.NOT FLUID RESISTANT.FOR COMFORT & HEATDISSIPATION. You may make one selection per column (Left, Extra Left, Right, and Extra Right) inBODILINK LATERAL PELVIC/THIGH SUPPORT HARDWARE3.3section 3.3 from group A, B, -OR- C. TT long extention arms (section 3.4) will only work with TT style hardware.HARDWARE SIZEVS. CUSHION THICKNESSTT HARDWARE, SLOT MOUNTFIXEDTT HARDWARESLOT MOUNTREMOVABLETT HARDWARESLOT MOUNT- FIXED4.0”- 6.5”3.0”- 4.5”2.0”- 3.0”SMALLLEFTEXTRA LEFTMEDIUMHARDWARE SIZEMAX SSSMALL3.0”2.0”- 3.0”MEDIUM4.5”3.0”- 4.5”LARGE6.5”4.0”- 6.5”LARGESIZEMSRPRIGHTEXTRA RIGHTSMALL S-TT1FXSL1-RHBL-LPTS-TT1FXSL1-RHMEDIUM S-TT1FXSL2-RHBL-LPTS-TT1FXSL2-RHLARGE S-TT1FXSL3-RHBL-LPTS-TT1FXSL3-RHSMALL S-TT1RMSL1-RHBL-LPTS-TT1RMSL1-RHMEDIUM S-TT1RMSL2-RHBL-LPTS-TT1RMSL2-RHLARGE S-TT1RMSL3-RHBL-LPTS-TT1RMSL3-RHM2-ORDER REV120320A.E1028REMOVABLEORM2 ORDER FORMClient Reference:*DO NOT SEND PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*PAGE 6 of 8

B.HARDWARE SIZEVS. CUSHION THICKNESS4.0”- 7.5”TT HARDWAREPOWER MOUNTREMOVABLETT HARDWAREPOWER MOUNT- FIXEDTT HARDWARE, POWER MOUNTMAX SS3.0”- 5.5”2.0”- 3.5”SMALLFIXEDHARDWARE SIZELEFTMEDIUMSMALL3.5”2.0”- 3.5”MEDIUM5.5”3.0”- 5.5”LARGE7.5”4.0”- 7.5”LARGESIZEMSRPEXTRA LEFTRIGHTEXTRA RIGHTSMALL PTS-TT1FXPWL1-RHBL-LPTS-TT1FXPWL1-RHMEDIUM PTS-TT1FXPWL2-RHBL-LPTS-TT1FXPWL2-RHLARGE PTS-TT1FXPWL3-RHBL-LPTS-TT1FXPWL3-RHSMALL PTS-TT1RMPWL1-RHBL-LPTS-TT1RMPWL1-RHMEDIUM PTS-TT1RMPWL2-RHBL-LPTS-TT1RMPWL2-RHLARGE PTS-TT1RMPWL3-RHBL-LPTS-TT1RMPWL3-RHTT HARDWARE, POWER MOUNT OPTIONNOTE: If choosing the Power Mount Hardware, choosethe appropriate power mount type below.POWER MOUNT44.1MSRP3.4add 0.00LPTS-TT1-PW1PERMOBILadd 0.00LPTS-TT1-PW2QUICKIEadd 0.00LPTS-TT1-PW3ROVIadd 0.00LPTS-TT1-PW4AVID REHABadd 0.00LPTS-TT1-PW5MSRP 37.00/armLEFTPART NUMBERQUANTUMTT LONG EXTENSION ARM 4”BL-LPTS-TT1LARM4BODILINK MEDIAL KNEE/THIGHSUPPORT HARDWARE & PADSPAD SIZE & SHAPEHCPCS CODING: E0957STYLEWWEDGEWOVALEXTRA LEFTRIGHTBL-LPTS-TT1LARM4SIZEPART NUMBER2.5”W x 3.5”DBL-MKTSP1-3W4D3.5”W x 5”DBL-MKTSP1-4W5D4”W x 6”DBL-MKTSP1-4W6D2.5”W x 3.5”DBL-MKTSP2-3W4D3.5”W x 5”DBL-MKTSP2-4W5D5”W x 6”DBL-MKTSP2-5W6DBL-LPTS-TT1LARM4PAD COVER MATERIALFOR SKIN PROTECTION& SHEAR REDUCTION.NOT FLUID RESISTANT.COMFORT-TEKSTRETCH-AIRFOR FLUID PROTECTION& AN EASILY CLEANEDSURFACE.FOR COMFORT& HEAT DISSIPATION.GlideWear (MKTSP-GLIDE) (add 15.00)COMFORT-TEK (MKTSP-COMFORT)STRETCH-AIR (MKTSP-STRETCH)DM2 ORDER FORMBL-LPTS-TT1LARM4 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 4.3.4.2MSRP 130.00EXTRA RIGHTClient Reference:*DO NOT SEND PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*PAGE 7 of 8M2-ORDER REV120320E1028REMOVABLEOR

MEDIAL KNEE/THIGH SUPPORTSWING AWAY HARDWAREHCPCS CODING: E1028MSRP 180.00SIZEPART ARGEBL-MKTS-ST1SASL3*Swing Away Hardware only, not available in Fixed Hardware**MKTS Hardware must be mounted to Removable Solid SeatPan in section 2.4***If Leg Length Discrepancy is needed on Removable SolidSeat Pan, Offset Orientation must be selectedSMALLInferior Thigh ThicknessMEDIUMLARGESIZERECOMMENDED INFERIORTHIGH THICKNESSSmall1.00”- 3.00”Medium2.00”- 5.00”Large3.00”- 7.00”M2-ORDER REV1203204.3The following are trademarks and registered trademarks of Permobil Seating and Positioning: COMFORT-TEK and STRETCH-AIR .GlideWear is a trademark of MIPS.M2 ORDER FORMClient Reference:*DO NOT SEND PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*SUBMIT BY EMAILPAGE 8 of 8

M2 ORDER FORM Client Reference: PAGE 1 of 10 *DO NOT SEND PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.* 402.00 402.00 431.00 431.00 1 SIZE & STYLE Comfort M2 Cushion Order Form HCPCS CODING: E2607/E2608 SKIN PROTECTION & POSITIONING SEAT CUSHION

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