ARM SUPPORT ORDER FORMd37xlajmpyyml6.cloudfront.net/standard_order_forms/... · 2016-06-08 ·...
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LEFT (1000L-HARD) RIGHT (1000R-HARD) LEFT (2100L-HARD) RIGHT (2100R-HARD) FIXED INTERLOCK (HARDWARE ONLY) MSRP $94.00 SLIDE ON (HARDWARE ONLY) MSRP $98.00 1.1 HARDWARE OPTIONS Depth-Adjustable Elevating LEFT (2000L-HARD) RIGHT (2000R-HARD) (ARMTM-P3-HARD) SWING AWAY (HARDWARE ONLY) MSRP $251.00 TRACK MOUNT* (HARDWARE ONLY) MSRP $120.00 LEFT (3000L-HARD) RIGHT (3000R-HARD) EAD HARDWARE (HARDWARE ONLY) MSRP $322.00 Articulating *Track Mount hardware for use with Quantum TRU-Balance 3 Seating System. HARDWARE 1 ARM SUPPORT ORDER FORM HCPCS CODING: E1028 - HARDWARE E2209 - ARM SUPPORT Company Name/ACCT #: P.O. Number: Requested By: Phone: Fax: Email: Ship To: Patient Reference: ARM-SUPPORT-ORDER REV0316 ARM SUPPORT ORDER FORM Patient Reference: PAGE 1 of 2 QUESTIONS? PLEASE CONTACT CUSTOMER SERVICE FOR ASSISTANCE. | 800.564.9248 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.
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Transcript of ARM SUPPORT ORDER FORMd37xlajmpyyml6.cloudfront.net/standard_order_forms/... · 2016-06-08 ·...
LEFT(1000L-HARD)
RIGHT(1000R-HARD)
LEFT(2100L-HARD)
RIGHT(2100R-HARD)
FIXED INTERLOCK(HARDWARE ONLY)
MSRP $94.00
SLIDE ON (HARDWARE ONLY)
MSRP $98.00
1.1 HARDWARE OPTIONS
Depth-Adjustable
Elevating
LEFT(2000L-HARD)
RIGHT(2000R-HARD)
(ARMTM-P3-HARD)
SWING AWAY(HARDWARE ONLY)
MSRP $251.00
TRACK MOUNT*(HARDWARE ONLY)
MSRP $120.00
LEFT(3000L-HARD)
RIGHT(3000R-HARD)
EAD HARDWARE (HARDWARE ONLY)
MSRP $322.00
Articulating
*Track Mount hardware for use with Quantum TRU-Balance3 Seating System.
HARDWARE1
ARM SUPPORTORDER FORMHCPCS CODING: E1028 - HARDWARE E2209 - ARM SUPPORT
Company Name/ACCT #:
P.O. Number:
Requested By:
Phone: Fax:
Email:
Ship To:
Patient Reference:
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ARM SUPPORT ORDER FORM Patient Reference: PAGE 1 of 2
QUESTIONS? PLEASE CONTACT CUSTOMER SERVICE FOR ASSISTANCE. | 800.564.9248
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.
Moldable option can be used to elevate fingers preventing edema.
* LOW ARM SHOWN
MOLDABLE OPTION
ARM SUPPORT PADS22.1 ARM SUPPORT PADS
LEFT SIDE Size RIGHT SIDE
2002L-14-PAD6” W x 14” D
2002R-14-PAD
2002L-17-PAD6” W x 17” D
2002R-17-PAD
2002L-PAD6” W x 22” D
2002R-PAD
2002L-M-PAD
6” W x 22” DMoldable Option 2002R-M-PAD
STANDARD ARMMSRP $138.00/ea
Moldable Option MSRP $160.00/ea
LEFT SIDE Size RIGHT SIDE
2300L-14-PAD14” D
2300R-14-PAD
2300L-PAD22” D
2300R-PAD
MOLDED ARMMSRP $73.00/ea
LEFT SIDE Size RIGHT SIDE
2004L-14-PAD6” W x 14” D
2004R-14-PAD
2004L-17-PAD6” W x 17” D
2004R-17-PAD
2004L-PAD6” W x 22” D
2004R-PAD
2004L-M-PAD
6” W x 22” DMoldable Option 2004R-M-PAD
LOW ARMMSRP $128.00/ea
Moldable Option MSRP $150.00/ea
LEFT SIDE Size RIGHT SIDE
2007L-PAD7” W x 22” D
2007R-PAD
2007L-M-PAD
7” W x 22” D Moldable Option 2007R-M-PAD
TALL RAILMSRP $160.00/ea
Moldable Option MSRP $182.00/ea
LEFT SIDE Size RIGHT SIDE
1005D3” W x 9” D
1005D
1005F3” W x 14” D
1005F
BASIC ARMMSRP $83.00/ea
*Track Mount hardware not available with Basic Arm.
COMFORT-TEK™ FABRICSELECTED FOR ITS ANTI-MICROBIAL PROPERTIES & AS AN EASILY CLEANED SURFACE.
ARM SUPPORT ORDER FORM Patient Reference: PAGE 2 of 2
QUESTIONS? PLEASE CONTACT CUSTOMER SERVICE FOR ASSISTANCE. | 800.564.9248
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SUBMIT BY EMAIL
