ELEMENTS® WITH GEL ORDER FORM Company Name/ACCT #:
HCPCS CODING: E2601/E2602 GENERAL USE
P.O. Number: Requested By:
2 inch Elements® with Gel shown
Phone:
Fax:
Email:
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 Service at
[email protected] or 1.406.522.8563.
1
SIZE & STYLE COMFORT-TEK™
STRETCH-AIR™
OR
SELECTED FOR INCONTINENCE PROTECTION & AN EASILY CLEANED SURFACE.
SELECTED FOR AIR TRANSMISSION & HEAT DISSIPATION.
2 INCH THICK ELEMENTS® with gel Please select size in the appropriate fabric chart below. 3 inch thick options found on page 2.
COMFORT-TEK™ $91.00
DEPTH
20”
46G-1620-B
46G-1720-B
46G-1820-B
$146.00 46G-1920-B
$191.00 46G-2020-B
46G-2120-B
46G-2220-B
$305.00
46G-2320-B
46G-2420-B
19”
46G-1619-B
46G-1719-B
46G-1819-B
46G-1919-B
46G-2019-B
46G-2119-B
46G-2219-B
46G-2319-B
46G-2419-B
18”
46G-1618-B
46G-1718-B
46G-1818-B
46G-1918-B
46G-2018-B
46G-2118-B
46G-2218-B
46G-2318-B
46G-2418-B
17”
46G-1617-B
46G-1717-B
46G-1817-B
46G-1917-B
46G-2017-B
46G-2117-B
46G-2217-B
46G-2317-B
46G-2417-B
16”
46G-1616-B
46G-1716-B
46G-1816-B
46G-1916-B
46G-2016-B
46G-2116-B
46G-2216-B
46G-2316-B
46G-2416-B
16”
17”
18”
19”
20”
21”
22”
23”
24”
WIDTH
STRETCH-AIR™
DEPTH
$91.00
$146.00
$191.00
$305.00
20”
46GS-1620-B
46GS-1720-B
46GS-1820-B
46GS-1920-B
46GS-2020-B
46GS-2120-B
46GS-2220-B
46GS-2320-B
46GS-2420-B
19”
46GS-1619-B
46GS-1719-B
46GS-1819-B
46GS-1919-B
46GS-2019-B
46GS-2119-B
46GS-2219-B
46GS-2319-B
46GS-2419-B
18”
46GS-1618-B
46GS-1718-B
46GS-1818-B
46GS-1918-B
46GS-2018-B
46GS-2118-B
46GS-2218-B
46GS-2318-B
46GS-2418-B
17”
46GS-1617-B
46GS-1717-B
46GS-1817-B
46GS-1917-B
46GS-2017-B
46GS-2117-B
46GS-2217-B
46GS-2317-B
46GS-2417-B
16”
46GS-1616-B
46GS-1716-B
46GS-1816-B
46GS-1916-B
46GS-2016-B
46GS-2116-B
46GS-2216-B
46GS-2316-B
46GS-2416-B
16”
17”
18”
19”
20”
21”
22”
23”
24”
WIDTH
ELEMENTS® WITH GEL ORDER FORM
Patient Reference:
PAGE 1 of 2
ELEMENTS-GEL-ORDER REV0416
Ship To:
COMFORT-TEK™
STRETCH-AIR™
OR
SELECTED FOR INCONTINENCE PROTECTION & AN EASILY CLEANED SURFACE.
SELECTED FOR AIR TRANSMISSION & HEAT DISSIPATION.
ELEMENTS-GEL-ORDER REV0416
3 INCH THICK ELEMENTS® with gel Please select size in the appropriate fabric chart below.
COMFORT-TEK™ $113.00
DEPTH
20”
463G-1620-B
463G-1720-B
463G-1820-B
$180.00 463G-1920-B
$201.00 463G-2020-B
463G-2120-B
463G-2220-B
$322.00
463G-2320-B
463G-2420-B
19”
463G-1619-B
463G-1719-B
463G-1819-B
463G-1919-B
463G-2019-B
463G-2119-B
463G-2219-B
463G-2319-B
463G-2419-B
18”
463G-1618-B
463G-1718-B
463G-1818-B
463G-1918-B
463G-2018-B
463G-2118-B
463G-2218-B
463G-2318-B
463G-2418-B
17”
463G-1617-B
463G-1717-B
463G-1817-B
463G-1917-B
463G-2017-B
463G-2117-B
463G-2217-B
463G-2317-B
463G-2417-B
16”
463G-1616-B
463G-1716-B
463G-1816-B
463G-1916-B
463G-2016-B
463G-2116-B
463G-2216-B
463G-2316-B
463G-2416-B
16”
17”
18”
19”
20”
21”
22”
23”
24”
WIDTH
STRETCH-AIR™
DEPTH
$113.00
$180.00
$201.00
$322.00
20”
463GS-1620-B
463GS-1720-B
463GS-1820-B
463GS-1920-B
463GS-2020-B
463GS-2120-B
463GS-2220-B
463GS-2320-B
463GS-2420-B
19”
463GS-1619-B
463GS-1719-B
463GS-1819-B
463GS-1919-B
463GS-2019-B
463GS-2119-B
463GS-2219-B
463GS-2319-B
463GS-2419-B
18”
463GS-1618-B
463GS-1718-B
463GS-1818-B
463GS-1918-B
463GS-2018-B
463GS-2118-B
463GS-2218-B
463GS-2318-B
463GS-2418-B
17”
463GS-1617-B
463GS-1717-B
463GS-1817-B
463GS-1917-B
463GS-2017-B
463GS-2117-B
463GS-2217-B
463GS-2317-B
463GS-2417-B
16”
463GS-1616-B
463GS-1716-B
463GS-1816-B
463GS-1916-B
463GS-2016-B
463GS-2116-B
463GS-2216-B
463GS-2316-B
463GS-2416-B
16”
17”
18”
19”
20”
21”
22”
23”
24”
WIDTH
QUESTIONS? PLEASE CONTACT CUSTOMER SERVICE FOR ASSISTANCE. | 800.564.9248
ELEMENTS® WITH GEL ORDER FORM
Patient Reference:
SUBMIT BY EMAIL
PAGE 2 of 2