75 Deep Height 425 Note 12 Wide NA with Deep Standard 1221 HD Cushion 2224 Note See chart at right for available sizes CUSHION DEPTH Standard 1221 HD Cushion 2224 Note See chart at right for available sizes NOTE Optional Step Only use this section ID: 45003
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o o ST: ZIP: () Fax:() ST: ZIP: o o () Fax:() J3Cushion(E2622/E2623 ) Note:UseE2623for22"WideandGreater CUSHIONHEIGHT StandardHeight-3.75" DeepHeight-4.25" Note:12"WideN/AwithDeep Standard(12"-21") HDCushion(22"-24") Note:Seechartatrightforavailablesizes CUSHIONDEPTH Standard(12"-21") HDCushion(22"-24") Note:Seechartatrightforavailablesizes (NOTE:OptionalStep- OnlyusethissectionwhenselectinganonstandardPLAsize ) PELVICLOADINGAREA(PLA)SIZE A-Small-Standard12"-15" B-Medium-Standard16"-19" C-Large-Standard20"-24" Note:PLAsizehasbeenoptimizedbaseduponanthropometricstudiesrelativetocushionwidth. Note:OptimalPLAsizingcanhelpprovidelowerIschialpressures,improvedstabilityandcomfortfortheuser. PLAINSERT FactoryFilled(FF)FluidPad FieldVariable(FV)FluidPad Note:FieldVariablecomesstandardwiththefollowingsupplementpads: PLAA=2-MediumPLAB=2-LargePLAC=2-Xlarge Email Dealer: ADDITIONALSHIPPINGINFORMATION DealerContact: Fax DealerCity: ConfirmationEmail: PO#: ShipToPhone: The HCPCSCODES providedarebasedoncodeverificationthroughPDACorourinterpretationofthecodedefinitions. Theuseof HCPCSCODES doesnotensurecoverageorpayment.Forcoverageinformation,verifytheappropriatepayer'scoveragepolicy. Date: ConfirmVia: DealerAcct#: DealerPhone: JAY ® J3 Cushion October2014 Quote Order ShipTo: Address: MarkFor: Submittingfor: DealerAddress: ShipToCity: Address: Attention: XX=Width Up-Charge o YY NC S D SelectPart#Up-Charge Selected Component ToorderaJ3Cushion,aJ3SMARTPartNumbermustbebuilt.FollowthestepsbelowtobuildyourownuniqueSmartPart#. Example Select o o Part#Up-Charge NC $30 Selected Component J3CUSHIONBASE SelectPart# J3C J3C CUSHIONWIDTH Selected Component Foradditionalinformation,pleaserefertotheJ3 CushionQuickReferenceGuide.Part#111903. o Charge $475 J3C Selected Component SorD SelectPart# o XX NC o XX $85 A,B,orC SelectPart# FF FV o YY NC YY=Depth C SelectPart# A B Up-Charge o NC o NC o NC Selected Component Up-Charge o NC o $10 Selected Component FForFV FactoryFilled FieldVariable 12"14"15"16"17"18"19"20"21"22"23"24" 12" S S 14" S 15" S 16" S 17" S 18" S 19" S 20" S 21" S 22" S 24" WIDTH SizeMatrix A a B (Aavailable) C (A&Bavailable) StdPLA D E P T H SpecialOrder N/A StandardSize AvailableinStd.HtOnly S CustomerService:800-333-4000Fax:800-300-7502Email:orders@sunmed.comwww.sunrisemedical.com Specificationsaresubjecttochangewithoutnotice.Copyright©2014SunriseMedical(US)LLC.J3CushionOct2014,MK-100112REV.A Page1 Continuedfrompage1 ROHOAIRPad-SingleValve ROHOAIRPad-DualValve Note:AirPadsshipwithinstructions,airpump,patchkitandnozzlefittings COVEROPTION Stretch Incontinent Microclimatic (OptionalStep) POSITIONINGCOMPONENTS PositioningComponents - E2624/E2625 Shipswithtwolateralthighpiecesasstandard PositioningComponents- E2622/E2623 OrderIndividualcomponentsusingconfigurator DoNotenter"P"intheSMARTpartnumber 2"LateralPelvis(pair)(UseK0108) ADD$20 2"MedialThigh(Single)(UseK0108) ADD$20 NotshownbutavailablethroughSunPartsOnline: 2"LateralThigh(Pair)(UseK0108) ADD$20 "PelvicObliquityPads"-examplepart#J3CDCOL Description ChangePLASize PLAsizedifferentthanStep3.AvailableA=12"-24",B=14"-24",C=16"-24"(S)or(D) NC (IPLAS) ChangePLALocation MovePLAlocation.PLASizeremainsthesame.Availabletomoveupto4"forward,1"leftorrightin1"increments NC (CPLAL) FemoralRelief FrontofPLAisadditionallycutawaytodecreasetheslopeanglefromthePLAtothefemoralsupportarea NC (FTR) ScrotalRelief FrontandcenterofPLAis"scooped"outtoaccommodateorgantissue. NC (SR) TrochantericRelief Basematerialremovedtocreatelesspressureatornearthetrochanters NC (TR) PositioningPieces IncludePositioningpieceswithcushionbutDONOTINSTALL.Allowsforcustominstallationinthefield. NC (DNIP) NotchforRails Notchfoambasetolowercushionbetweentheseatrails. NC (NR) FluidVolumeChanges Removeoraddfluidtotheentirebladdertoachieveidealimmersion. NC (UForOF) LegTroughCut Forimprovedpositioning,usethismodificationtoincreasethedepth~1"ofthefemoraltroughtosupportthefemurs. NC (LTC) Embroidery Addpersonalizationforidentificationpurposes.(Hint:Greatforlargefacilitiesorproductidentificationduringcleaning) NC N/A Note:MultiplecombinationsoftheseMODSarepossible.CommonexampleisFemoralTransitionandScrotal.Pleasecontactcustomerserviceforcombinations Note:Ifthereisamodificationthatisnotlistedabove,contactcustomerserviceandwewilldoourbesttoaccommodateyourneeds. NOTES POSITIONINGCOMPONENTS (Ifapplicable) PRICE MODIFICATIONDiagrams .TheredcirclesDONOTrepresenttheactualshapeofthecutouts.Theaffectedareaswillresultinsmoothtransitionsandsubtlechangesthat assistinthelesseningofpressureinspecificareasofthecushionbase.TheseredcirclesonlyhighlighttheareaofthebasethattheMODwillaffect J3C SelectPart#Up-Charge o AS $55 o AD $60 Selected Component o S ROHOAIR-Single ROHOAIR-Dual SelectPart#Up-Charge Selected Component SelectPart#Up-Charge NC o I NC o M NC ASorAD S,I,orM o Part# $20 Selected Component P OPTIONALMODIFICATIONS Note:Pleasecontactcustomerservicetodiscussyourmodificaitonoptions.SomeMODSmaypreventtheuseofthereducerringsand/orpositioningpieces CODE Up-Charge Modification J3SMARTPART# Pleasevisitwww.sunparts.usforsparepartsinformation. Step7 Step6 Step5 Step4 Step3 Step2 Step1 MovePLALocation FemoralRelief TrochantericRelief ScrotalRelief LegTroughCut CustomerService:800-333-4000Fax:800-300-7502Email:orders@sunmed.comwww.sunrisemedical.com Specificationsaresubjecttochangewithoutnotice.Copyright©2014SunriseMedical(US)LLC.J3CushionOct2014,MK-100112REV.A Page2