Jay Union Order Form

Jay Union Order Form
®
JAY Union TM
Cushion
September 2014
SUBMIT
Mark For:
Submitting for:
Date:
PO#:
o Quote
o Order
Dealer Acct #:
Dealer:
ADDITIONAL SHIPPING INFORMATION
Dealer Contact:
Ship To:
Dealer Address:
Attention:
Dealer City:
ST:
Dealer Phone: (
Confirmation Email:
)
Address:
ZIP:
Fax: (
Address:
)
Ship To City:
o Fax
Confirm Via:
o Email
ST:
Ship To Phone: (
)
ZIP:
Fax: (
)
The HCPCS CODES provided are based on code verification through PDAC or our interpretation of the code definitions.
The use of HCPCS CODES does not ensure coverage or payment. For coverage information, verify the appropriate payer's coverage policy.
a
Option #
HCPCS Definition
Price
JAY UNION CUSHION
o
JAY Union Reduced Profile Cushion
Includes: X-Static fabric outer cover, inner cover, and hybrid foam/fluid base
Note: Reduced profile option is 1" shorter in height for an overall height of 3.5"
Note: XX = Width and YY = Depth (Select appropriate assembly # on page 2)
JUXXYYRP
E2607 JAY Union Cushion 14-20 wide
$445.00
JAY Union Cushion w/ Second Outer Cover
Includes: (2)X-Static fabric outer covers, (1)inner cover, and (1)hybrid foam/fluid base
Note: XX = Width and YY = Depth (Select appropriate assembly # on page 2)
JUXXYY-2
E2607 JAY Union Cushion 14-21 wide
$545.00
o
JUXXYY-2
E2608 JAY Union Cushion 22-24 wide
$645.00
o
JAY Union
The JAY Union utilizes a dynamic, fluid imprint. The fluid assists in matching the foam to
each individual’s pelvic contour.
JAY Union Size Matrix
DEPTH
o
o
JAY Union Cushion
Includes: X-Static fabric outer cover, inner cover, and hybrid foam/fluid base
Note: XX = Width and YY = Depth (Select appropriate assembly # on page 2)
JUXXYY
E2607 JAY Union Cushion 14-21 wide
$445.00
JUXXYY
E2608 JAY Union Cushion 22-24 wide
$545.00
14
15
16
17
18
19
20
21
22
23
24
WIDTH
14 15 16 17 18 19 20 21 22 23 24
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
=
=
=
=
JYW
N/A
*
N/A
N/A
N/A
N/A
N/A N/A N/A N/A N/A N/A
N/A N/A N/A N/A
N/A N/A N/A N/A
*
* N/A N/A
*
* N/A N/A
*
*
* N/A
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
N/A N/A *
*
*
*
*
*
N/A N/A *
*
*
*
*
*
Standard Offering
Offered Via Jay Your Way
Not available
Not available w/ Reduced Profile
JAY Union Measuring Guide
Measurements made from completed cushion with covers.
Outer Cover
Inner Cover
The JAY Union outer cover is designed to
promote comfort, convenience and
breathability by the use of "X-Static"
material and 3DX Spacer Fabric.
The water resistant inner cover,
combined with the Aquaguard™ Zipper
and anti wicking thread provides the
ultimate protection against odor.
Width
X = Width
Note: Measurement made
from bottom outside edge
to outside edge of cushion.
Ex: JU1618 X = 16"
X"
Depth
Y"
Y = Depth
Note: Measurement made
from bottom front edge to
bottom rear edge of
cushion.
Ex: JU1618 Y = 18"
Bottom View
Note: To order via JAY Your Way add a "M" to the front of the part number and follow the prompts.
For additional modifications see Page 2 or visit www.sunrisemedical.com to view even more!
Please visit www.sunparts.us for spare parts information.
Customer Service: 800-333-4000 Fax: 800-300-7502 Email: orders@sunmed.com www.sunrisemedical.com
Specifications are subject to change without notice. Copyright © 2014 Sunrise Medical (US) LLC. Union September 2014, MK-100091 REV.A
Page 1
JAY UNION CUSHION
Price
a
Option #
$445
o
JU1922
$445
o
JU1923
$445
o
JU2015
$445
o
JU2016
$445
o
JU2017
$445
o
JU2018
$445
o
JU2019
$445
o
JU2020
$445
o
JU2021
$445
o
JU2022
$445
o
JU2023
$445
o
JU2024
$445
o
JU2117
$445
o
JU2118
$445
o
JU2119
$445
o
JU2120
$445
o
JU2121
$445
o
JU2122
$445
o
JU2123
$445
o
JU2124
a
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Option #
HCPCS
JU1414
E2607
JAY UNION 14" X 14"
JU1415
E2607
JAY UNION 14" X 15"
JU1416
E2607
JAY UNION 14" X 16"
JU1417
E2607
JAY UNION 14" X 17"
JU1418
E2607
JAY UNION 14" X 18"
JU1514
E2607
JAY UNION 15" X 14"
JU1515
E2607
JAY UNION 15" X 15"
JU1516
E2607
JAY UNION 15" X 16"
JU1517
E2607
JAY UNION 15" X 17"
JU1518
E2607
JAY UNION 15" X 18"
JU1519
E2607
JAY UNION 15" X 19"
JU1520
E2607
JAY UNION 15" X 20"
JU1614
E2607
JAY UNION 16" X 14"
JU1615
E2607
JAY UNION 16" X 15"
JU1616
E2607
JAY UNION 16" X 16"
JU1617
E2607
JAY UNION 16" X 17"
JU1618
E2607
JAY UNION 16" X 18"
JU1619
E2607
JAY UNION 16" X 19"
JU1620
E2607
JAY UNION 16" X 20"
JU1714
E2607
JAY UNION 17" X 14"
JU1715
E2607
JAY UNION 17" X 15"
$445
JU1716
E2607
JAY UNION 17" X 16"
$445
JU1717
E2607
JAY UNION 17" X 17"
$445
JU1718
E2607
JAY UNION 17" X 18"
$445
JU1719
E2607
JAY UNION 17" X 19"
$445
JU1720
E2607
JAY UNION 17" X 20"
$445
JU1721
E2607
JAY UNION 17" X 21"
$445
JU1814
E2607
JAY UNION 18" X 14"
$445
JU1815
E2607
JAY UNION 18" X 15"
$445
JU1816
E2607
JAY UNION 18" X 16"
$445
JU1817
E2607
JAY UNION 18" X 17"
$445
JU1818
E2607
JAY UNION 18" X 18"
$445
JU1819
E2607
JAY UNION 18" X 19"
$445
JU1820
E2607
JAY UNION 18" X 20"
$445
JU1821
E2607
JAY UNION 18" X 21"
$445
JU1822
E2607
JAY UNION 18" X 22"
$445
JU1915
E2607
JAY UNION 19" X 15"
$445
JU1916
E2607
JAY UNION 19" X 16"
$445
JU1917
E2607
JAY UNION 19" X 17"
$445
JU1918
E2607
JAY UNION 19" X 18"
$445
JU1919
E2607
JAY UNION 19" X 19"
$445
JU1920
E2607
JAY UNION 19" X 20"
$445
JU1921
E2607
JAY UNION 19" X 21"
$445
a
Option Code
o
NR
Definition
Definition
HCPCS
NOTCH FOR SEAT RAILS
NC
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
NOTCH FOR BACK POST
o
NP
o
Cover Options
NC
o Incontinent
o 3"
FZP
o
LLCR
$445
E2607
JAY UNION 20" X 15"
$445
E2607
JAY UNION 20" X 16"
$445
E2607
JAY UNION 20" X 17"
$445
E2607
JAY UNION 20" X 18"
$445
E2607
JAY UNION 20" X 19"
$445
E2607
JAY UNION 20" X 20"
$445
E2607
JAY UNION 20" X 21"
$445
E2607
JAY UNION 20" X 22"
$445
E2607
JAY UNION 20" X 23"
$445
E2607
JAY UNION 20" X 24"
$445
E2607
JAY UNION 21" X 17"
$445
E2607
JAY UNION 21" X 18"
$445
E2607
JAY UNION 21" X 19"
$445
E2607
JAY UNION 21" X 20"
$445
E2607
JAY UNION 21" X 21"
$445
E2607
JAY UNION 21" X 22"
$445
E2607
JAY UNION 21" X 23"
$445
E2607
JAY UNION 21" X 24"
$445
E2608
JAY UNION 22" X 17"
$545
JU2218
E2608
JAY UNION 22" X 18"
$545
JU2219
E2608
JAY UNION 22" X 19"
$545
JU2220
E2608
JAY UNION 22" X 20"
$545
JU2221
E2608
JAY UNION 22" X 21"
$545
JU2222
E2608
JAY UNION 22" X 22"
$545
JU2223
E2608
JAY UNION 22" X 23"
$545
JU2224
E2608
JAY UNION 22" X 24"
$545
JU2319
E2608
JAY UNION 23" X 19"
$545
JU2320
E2608
JAY UNION 23" X 20"
$545
JU2321
E2608
JAY UNION 23" X 21"
$545
JU2322
E2608
JAY UNION 23" X 22"
$545
JU2323
E2608
JAY UNION 23" X 23"
$545
JU2324
E2608
JAY UNION 23" X 24"
$545
JU2418
E2608
JAY UNION 24" X 18"
$545
JU2419
E2608
JAY UNION 24" X 19"
$545
JU2420
E2608
JAY UNION 24" X 20"
$545
JU2421
E2608
JAY UNION 24" X 21"
$545
JU2422
E2608
JAY UNION 24" X 22"
$545
JU2423
E2608
JAY UNION 24" X 23"
$545
JU2424
E2608
JAY UNION 24" X 24"
$545
Definition
HCPCS
ANTERIOR OR POSTERIOR SLOPE
WGP
Front Zippered Pocket
NC
Posterior Slope - Wedge
WGA
.5"
o
1"
o
1.5"
NC
1"
o
1.5"
Anterior Slope - Wedge
Wedge glued underneath cushion (Cover sewn to match)
NC
o Microclimatic
$25
Select desired height increase at rear of cushion
o
.5"
o
Don't see the option you want? NO PROBLEM! Write your request below
and we can evaluate it and provide a quote.
Notes:
LEG LENGTH DISCREPANCY
o
o
Remove 1"
Leg Length Cut Right Side
o
LLCL
o
Remove 1"
NC
Remove 2"
Leg Length Cut Left Side
o
Price
Select desired height increase at front of cushion
o
FRONT POCKET
o
JAY UNION 19" X 23"
o
o 2"
COVER OPTIONS
o Stretch
$445
E2607
Wedge glued underneath cushion (Cover sewn to match)
Notch for Back Post
CVR
JAY UNION 19" X 22"
JU2217
Specify distance from back of cushion:
o 1"
Price
E2607
22" & Greater in Width
JAY Your Way - Modifications
Price
a
Option Code
Notch for Seat Rails
Definition
HCPCS
NC
Remove 2"
Customer Service: 800-333-4000 Fax: 800-300-7502 Email: orders@sunmed.com www.sunrisemedical.com
Specifications are subject to change without notice. Copyright © 2014 Sunrise Medical (US) LLC. Union September 2014, MK-100091 REV.A
Page 2
a
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Definition
Option #
HCPCS
JU1414RP
E2607
JAY UNION 14" X 14"
JU1415RP
E2607
JAY UNION 14" X 15"
JU1416RP
E2607
JAY UNION 14" X 16"
JU1417RP
E2607
JAY UNION 14" X 17"
JU1418RP
E2607
JAY UNION 14" X 18"
JU1514RP
E2607
JAY UNION 15" X 14"
JU1515RP
E2607
JAY UNION 15" X 15"
JU1516RP
E2607
JAY UNION 15" X 16"
JU1517RP
E2607
JAY UNION 15" X 17"
JU1518RP
E2607
JAY UNION 15" X 18"
JU1519RP
E2607
JAY UNION 15" X 19"
JU1520RP
E2607
JAY UNION 15" X 20"
JU1614RP
E2607
JAY UNION 16" X 14"
JU1615RP
E2607
JAY UNION 16" X 15"
JU1616RP
E2607
JAY UNION 16" X 16"
JU1617RP
E2607
JAY UNION 16" X 17"
JU1618RP
E2607
JAY UNION 16" X 18"
JU1619RP
E2607
JAY UNION 16" X 19"
JU1620RP
E2607
JAY UNION 16" X 20"
JU1714RP
E2607
JAY UNION 17" X 14"
JU1715RP
E2607
JAY UNION 17" X 15"
JU1716RP
E2607
JAY UNION 17" X 16"
JU1717RP
E2607
JAY UNION 17" X 17"
JAY UNION REDUCED PROFILE CUSHION
Price
a
Option #
$445
o
JU1718RP
$445
o
JU1719RP
$445
o
JU1720RP
$445
o
JU1814RP
$445
o
JU1815RP
$445
o
JU1816RP
$445
o
JU1817RP
$445
o
JU1818RP
$445
o
JU1819RP
$445
o
JU1820RP
$445
o
JU1915RP
$445
o
JU1916RP
$445
o
JU1917RP
$445
o
JU1918RP
$445
o
JU1919RP
$445
o
JU1920RP
$445
o
JU2015RP
$445
o
JU2016RP
$445
o
JU2017RP
$445
o
JU2018RP
$445
o
JU2019RP
$445
o
JU2020RP
HCPCS
Definition
Price
E2607
JAY UNION 17" X 18"
$445
E2607
JAY UNION 17" X 19"
$445
E2607
JAY UNION 17" X 20"
$445
E2607
JAY UNION 18" X 14"
$445
E2607
JAY UNION 18" X 15"
$445
E2607
JAY UNION 18" X 16"
$445
E2607
JAY UNION 18" X 17"
$445
E2607
JAY UNION 18" X 18"
$445
E2607
JAY UNION 18" X 19"
$445
E2607
JAY UNION 18" X 20"
$445
E2607
JAY UNION 19" X 15"
$445
E2607
JAY UNION 19" X 16"
$445
E2607
JAY UNION 19" X 17"
$445
E2607
JAY UNION 19" X 18"
$445
E2607
JAY UNION 19" X 19"
$445
E2607
JAY UNION 19" X 20"
$445
E2607
JAY UNION 20" X 15"
$445
E2607
JAY UNION 20" X 16"
$445
E2607
JAY UNION 20" X 17"
$445
E2607
JAY UNION 20" X 18"
$445
E2607
JAY UNION 20" X 19"
$445
E2607
JAY UNION 20" X 20"
$445
$445
Customer Service: 800-333-4000 Fax: 800-300-7502 Email: orders@sunmed.com www.sunrisemedical.com
Specifications are subject to change without notice. Copyright © 2014 Sunrise Medical (US) LLC. Union September 2014, MK-100091 REV.A
Page 3
JAY UNION CUSHION WITH SECOND COVER
a
Option #
a
Option #
o
JU1414-2
E2607 E2619
JAY UNION 14" X 14"
$545
o
JU1922-2
E2607 E2619
JAY UNION 19" X 22"
$545
o
JU1415-2
E2607 E2619
JAY UNION 14" X 15"
$545
o
JU1923-2
E2607 E2619
JAY UNION 19" X 23"
$545
o
JU1416-2
E2607 E2619
JAY UNION 14" X 16"
$545
o
JU2015-2
E2607 E2619
JAY UNION 20" X 15"
$545
o
JU1417-2
E2607 E2619
JAY UNION 14" X 17"
$545
o
JU2016-2
E2607 E2619
JAY UNION 20" X 16"
$545
o
JU1418-2
E2607 E2619
JAY UNION 14" X 18"
$545
o
JU2017-2
E2607 E2619
JAY UNION 20" X 17"
$545
o
JU1514-2
E2607 E2619
JAY UNION 15" X 14"
$545
o
JU2018-2
E2607 E2619
JAY UNION 20" X 18"
$545
JU1515-2
E2607 E2619
JAY UNION 15" X 15"
$545
o
JU2019-2
E2607 E2619
JAY UNION 20" X 19"
$545
o
o
o
HCPCS
Definition
Price
HCPCS
Definition
Price
JU1516-2
E2607 E2619
JAY UNION 15" X 16"
$545
JU2020-2
E2607 E2619
JAY UNION 20" X 20"
$545
o
JU1517-2
E2607 E2619
JAY UNION 15" X 17"
$545
o
JU2021-2
E2607 E2619
JAY UNION 20" X 21"
$545
o
JU1518-2
E2607 E2619
JAY UNION 15" X 18"
$545
o
JU2022-2
E2607 E2619
JAY UNION 20" X 22"
$545
o
JU1519-2
E2607 E2619
JAY UNION 15" X 19"
$545
o
JU2023-2
E2607 E2619
JAY UNION 20" X 23"
$545
o
JU1520-2
E2607 E2619
JAY UNION 15" X 20"
$545
o
JU2024-2
E2607 E2619
JAY UNION 20" X 24"
$545
o
JU1614-2
E2607 E2619
JAY UNION 16" X 14"
$545
o
JU2117-2
E2607 E2619
JAY UNION 21" X 17"
$545
o
JU1615-2
E2607 E2619
JAY UNION 16" X 15"
$545
o
JU2118-2
E2607 E2619
JAY UNION 21" X 18"
$545
o
JU1616-2
E2607 E2619
JAY UNION 16" X 16"
$545
o
JU2119-2
E2607 E2619
JAY UNION 21" X 19"
$545
o
JU1617-2
E2607 E2619
JAY UNION 16" X 17"
$545
o
JU2120-2
E2607 E2619
JAY UNION 21" X 20"
$545
o
JU1618-2
E2607 E2619
JAY UNION 16" X 18"
$545
o
JU2121-2
E2607 E2619
JAY UNION 21" X 21"
$545
JU1619-2
E2607 E2619
JAY UNION 16" X 19"
$545
o
JU2122-2
E2607 E2619
JAY UNION 21" X 22"
$545
o
JU2123-2
E2607 E2619
JAY UNION 21" X 23"
$545
o
JU2124-2
E2607 E2619
JAY UNION 21" X 24"
$545
o
o
JU1620-2
E2607 E2619
JAY UNION 16" X 20"
$545
o
JU1714-2
E2607 E2619
JAY UNION 17" X 14"
$545
o
JU1715-2
E2607 E2619
JAY UNION 17" X 15"
$545
o
JU1716-2
E2607 E2619
JAY UNION 17" X 16"
$545
o
JU2217-2
E2608 E2619
JAY UNION 22" X 17"
$645
o
JU1717-2
E2607 E2619
JAY UNION 17" X 17"
$545
o
JU2218-2
E2608 E2619
JAY UNION 22" X 18"
$645
o
JU1718-2
E2607 E2619
JAY UNION 17" X 18"
$545
o
JU2219-2
E2608 E2619
JAY UNION 22" X 19"
$645
o
JU1719-2
E2607 E2619
JAY UNION 17" X 19"
$545
o
JU2220-2
E2608 E2619
JAY UNION 22" X 20"
$645
o
JU1720-2
E2607 E2619
JAY UNION 17" X 20"
$545
o
JU2221-2
E2608 E2619
JAY UNION 22" X 21"
$645
o
JU1721-2
E2607 E2619
JAY UNION 17" X 21"
$545
o
JU2222-2
E2608 E2619
JAY UNION 22" X 22"
$645
o
JU1814-2
E2607 E2619
JAY UNION 18" X 14"
$545
o
JU2223-2
E2608 E2619
JAY UNION 22" X 23"
$645
o
JU1815-2
E2607 E2619
JAY UNION 18" X 15"
$545
o
JU2224-2
E2608 E2619
JAY UNION 22" X 24"
$645
o
o
22" & Greater in Width
JU1816-2
E2607 E2619
JAY UNION 18" X 16"
$545
JU2319-2
E2608 E2619
JAY UNION 23" X 19"
$645
o
JU1817-2
E2607 E2619
JAY UNION 18" X 17"
$545
o
JU2320-2
E2608 E2619
JAY UNION 23" X 20"
$645
o
JU1818-2
E2607 E2619
JAY UNION 18" X 18"
$545
o
JU2321-2
E2608 E2619
JAY UNION 23" X 21"
$645
o
JU1819-2
E2607 E2619
JAY UNION 18" X 19"
$545
o
JU2322-2
E2608 E2619
JAY UNION 23" X 22"
$645
o
JU1820-2
E2607 E2619
JAY UNION 18" X 20"
$545
o
JU2323-2
E2608 E2619
JAY UNION 23" X 23"
$645
o
JU1821-2
E2607 E2619
JAY UNION 18" X 21"
$545
o
JU2324-2
E2608 E2619
JAY UNION 23" X 24"
$645
o
JU1822-2
E2607 E2619
JAY UNION 18" X 22"
$545
o
JU2418-2
E2608 E2619
JAY UNION 24" X 18"
$645
o
JU1915-2
E2607 E2619
JAY UNION 19" X 15"
$545
o
JU2419-2
E2608 E2619
JAY UNION 24" X 19"
$645
o
JU1916-2
E2607 E2619
JAY UNION 19" X 16"
$545
o
JU2420-2
E2608 E2619
JAY UNION 24" X 20"
$645
o
JU1917-2
E2607 E2619
JAY UNION 19" X 17"
$545
o
JU2421-2
E2608 E2619
JAY UNION 24" X 21"
$645
o
JU1918-2
E2607 E2619
JAY UNION 19" X 18"
$545
o
JU2422-2
E2608 E2619
JAY UNION 24" X 22"
$645
o
JU2423-2
E2608 E2619
JAY UNION 24" X 23"
$645
o
JU2424-2
E2608 E2619
JAY UNION 24" X 24"
$645
o
JU1919-2
E2607 E2619
JAY UNION 19" X 19"
$545
o
JU1920-2
E2607 E2619
JAY UNION 19" X 20"
$545
o
JU1921-2
E2607 E2619
JAY UNION 19" X 21"
$545
Customer Service: 800-333-4000 Fax: 800-300-7502 Email: orders@sunmed.com www.sunrisemedical.com
Specifications are subject to change without notice. Copyright © 2014 Sunrise Medical (US) LLC. Union September 2014, MK-100091 REV.A
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