CUSTOM ACTA-BACK ® DEEP - SHORT ORDER FORM HCPCS CODE: E2617 1 BACK SUPPORT SIZE C - D - W H HCPCS Code: E2617 2 COVER OPTIONS 4 CUSTOM FOAM SELECTION REAR LAYER (REQUIRED) $0.00 H.R. MEDIUM 1/4” (CD-REAR-HRM-0.25) 1/2” (CD-REAR-HRM-0.50) 3/4” (CD-REAR-HRM-0.75) SFC 1” (CD-REAR-HRM-1.00) 1 1/4” (CD-REAR-HRM-1.25) H.R. SOFT 1/4” (CD-REAR-HRS-0.25) 1/2” (CD-REAR-HRS-0.50) 3/4” (CD-REAR-HRS-0.75) 1” (CD-REAR-HRS-1.00) 1 1/4” (CD-REAR-HRS-1.25) VISCOOL TM MEDIUM 1/2” (CD-REAR-VIS-M-0.50) 1” (CD-REAR-VIS-M-1.00) VISCOOL TM SOFT 1/2” (CD-REAR-VIS-S-0.50) 1” (CD-REAR-VIS-S-1.00) VISCOOL TM EXTRA SOFT 1/2” (CD-REAR-VIS-XS-0.50) 1” (CD-REAR-VIS-XS-1.00) VISCO EXTRA EXTRA SOFT 1/2” (CD-REAR-VIS-XXS-0.50) 1” (CD-REAR-VIS-XXS-1.00) MIDDLE LAYER (OPTIONAL) H.R. MEDIUM 1/4” (CD-MID-HRM-0.25) 1/2” (CD-MID-HRM-0.50) 3/4” (CD-MID-HRM-0.75) 1” (CD-MID-HRM-1.00) 1 1/4” (CD-MID-HRM-1.25) H.R. SOFT 1/4” (CD-MID-HRS-0.25) 1/2” (CD-MID-HRS-0.50) 3/4” (CD-MID-HRS-0.75) 1” (CD-MID-HRS-1.00) 1 1/4” (CD-MID-HRS-1.25) VISCOOL TM MEDIUM 1/2” (CD-MID-VIS-M-0.50) 1” (CD-MID-VIS-M-1.00) VISCOOL TM SOFT 1/2” (CD-MID-VIS-S-0.50) 1” (CD-MID-VIS-S-1.00) VISCOOL TM EXTRA SOFT 1/2” (CD-MID-VIS-XS-0.50) 1” (CD-MID-VIS-XS-1.00) VISCO EXTRA EXTRA SOFT 1/2” (CD-MID-VIS-XXS-0.50) 1” (CD-MID-VIS-XXS-1.00) TOPPER LAYER (OPTIONAL) H.R. MEDIUM 1/4” (CD-TOP-HRM-0.25) 1/2” (CD-TOP-HRM-0.50) 3/4” (CD-TOP-HRM-0.75) 1” (CD-TOP-HRM-1.00) 1 1/4” (CD-TOP-HRM-1.25) H.R. SOFT 1/4” (CD-TOP-HRS-0.25) 1/2” (CD-TOP-HRS-0.50) 3/4” (CD-TOP-HRS-0.75) 1” (CD-TOP-HRS-1.00) 1 1/4” (CD-TOP-HRS-1.25) VISCOOL TM MEDIUM 1/2” (CD-TOP-VIS-M-0.50) 1” (CD-TOP-VIS-M-1.00) VISCOOL TM SOFT 1/2” (CD-TOP-VIS-S-0.50) 1” (CD-TOP-VIS-S-1.00) VISCOOL TM EXTRA SOFT 1/2” (CD-TOP-VIS-XS-0.50) 1” (CD-TOP-VIS-XS-1.00) VISCO EXTRA EXTRA SOFT 1/2” (CD-TOP-VIS-XXS-0.50) SFC 1” (CD-TOP-VIS-XXS-1.00) Rear Layer Middle Layer Topper Layer A minimum of one layer must be chosen. A ¼” Crosslink foundation layer comes standard on all back supports. $0.00 $133.33 $133.33 $133.33 $133.33 $0.00 $0.00 $133.33 $133.33 $133.33 $133.33 $0.00 $0.00 $133.33 $133.33 $133.33 $133.33 12-20” Width / 12-18” Length = $1037.33 Base Price 21-24” Width / 12-18” Length = $1140.00 Base Price 12-24” Width / 19-22” Length = $1170.67 Base Price 25-28” Width / 12-22” Length = $1682.67 Base Price *If desired size is not listed above, a 60% up charge will be applied for materials. STRETCH-AIR W/ DIAMOND $0.00 (CD-STRETCH-AIR) (CD-DIGI-STRETCH-AIR) COMFORT-TEK W/ DIAMOND $0.00 (CD-COMFORT-TEK) (CD-DIGI-COMFORT-TEK) STRETCH-AIR W/ DIGI-CAMO $0.00 COMFORT-TEK W/ DIGI-CAMO $0.00 3 MILITARY BRANCH PATCH AIR FORCE $0.00 (CD-AIR-FORCE-PATCH) ARMY $0.00 (CD-ARMY-PATCH) MARINES $0.00 (CD-MARINES-PATCH) NAVY $0.00 (CD-NAVY-PATCH) (OPTIONAL) Company Name/ACCT #: P.O. Number: Requested By: Phone: Fax: Email: Ship To: Patient Reference: 5 MOLDABLE ALUMINUM STAYS SPACE BETWEEN STAYS $0.00 Back support comes with two aluminum stays that can be molded to support spinal curvature. Stays are offset from the spine and held in place by pockets sewn into the rear of the cover. 1” (CD-STAY-1.0) 1 1/2” (CD-STAY-1.5) 2” (CD-STAY-2.0) 2 1/2” (CD-STAY-2.5) 3” (CD-STAY-3.0) 3 1/2” (CD-STAY-3.5) 4” (CD-STAY-4.0) 4 1/2” (CD-STAY-4.5) SPECIFY CUSTOM SPACING (CD-STAY-OTHER) NONE (CD-STAY-NONE) Aluminum Stay Pockets Moldable Aluminum Stays Choose either Stretch-Air or Comfort-Tek cover fabric with Diamond or Digi-Camo accent fabric. Care for each accent fabric is identical. CD-ACTA-BACK-DEEP-SHORTFORM REV0218 1/3 NOTE: Desired back support length is “H” dimension in part number above. Cover appearance may vary with hardware selection and size. 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 to [email protected] or print and fax to 1.406.522.8563. STRETCH-AIR has comfortable stretch, air transmission and heat dissipation. It is not fluid resistant. COMFORT-TEK is a smooth, easily cleaned surface. The fluid protection aids in infection control. SFC = Standard Foam Configuration. Use as a reference when choosing foam layers. = 1” (CD-TOP-VIS-XXS-1.00) SFC
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CUSTOM ACTA-BACK® DEEP - SHORT ORDER FORMHCPCS CODE: E2617
A minimum of one layer must be chosen. A ¼” Crosslink foundation layer comes standard on all back supports.
$0.00
$133.33
$133.33
$133.33
$133.33
$0.00
$0.00
$133.33
$133.33
$133.33
$133.33
$0.00
$0.00
$133.33
$133.33
$133.33
$133.33
12-20” Width / 12-18” Length = $1037.33 Base Price21-24” Width / 12-18” Length = $1140.00 Base Price12-24” Width / 19-22” Length = $1170.67 Base Price25-28” Width / 12-22” Length = $1682.67 Base Price
*If desired size is not listed above, a 60% up charge will be applied for materials.
STRETCH-AIR W/ DIAMOND $0.00(CD-STRETCH-AIR)
(CD-DIGI-STRETCH-AIR)
COMFORT-TEK W/ DIAMOND $0.00(CD-COMFORT-TEK)
(CD-DIGI-COMFORT-TEK)
STRETCH-AIR W/ DIGI-CAMO $0.00
COMFORT-TEK W/ DIGI-CAMO $0.00
3 MILITARY BRANCH PATCH
AIR FORCE $0.00(CD-AIR-FORCE-PATCH)
ARMY $0.00(CD-ARMY-PATCH)
MARINES $0.00(CD-MARINES-PATCH)
NAVY $0.00(CD-NAVY-PATCH)
(OPTIONAL)
Company Name/ACCT #:
P.O. Number:
Requested By:
Phone: Fax:
Email:
Ship To:
Patient Reference:
5 MOLDABLE ALUMINUM STAYSSPACE BETWEEN STAYS $0.00
Back support comes with two aluminum stays that can be molded to support spinal curvature. Stays are offset from the spine and held in place by pockets sewn into the rear of the cover.
1” (CD-STAY-1.0)
1 1/2” (CD-STAY-1.5)
2” (CD-STAY-2.0)
2 1/2” (CD-STAY-2.5)
3” (CD-STAY-3.0)
3 1/2” (CD-STAY-3.5)
4” (CD-STAY-4.0)
4 1/2” (CD-STAY-4.5)
SPECIFY CUSTOM SPACING (CD-STAY-OTHER)
NONE (CD-STAY-NONE)
Aluminum Stay Pockets
Moldable Aluminum Stays
Choose either Stretch-Air or Comfort-Tek cover fabric with Diamond or Digi-Camo accent fabric. Care for each accent fabric is identical.
CD-ACTA-BACK-DEEP-SHORTFORMREV0218
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NOTE: Desired back support length is “H” dimension in part number above. Cover appearance may vary with hardware selection and size.
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 to [email protected] or print and fax to 1.406.522.8563.
STRETCH-AIR has comfortable stretch, air transmission and heat dissipation. It is not fluid resistant.
COMFORT-TEK is a smooth, easily cleaned surface. The fluid protection aids in infection control.
SFC = Standard Foam Configuration. Use as a reference when choosing foam layers. =1” (CD-TOP-VIS-XXS-1.00) SFC
7 COLOR (OPTIONAL)COLOR
Accent colors are applied via colored piping. If no color is selected, our standard silver reflective piping will be used. Placement may vary by hardware being used.
$0.00
RED (CD-RED)
PURPLE (CD-PURPLE)
PINK (CD-PINK)
BLUE (CD-BLUE)
GREEN (CD-GREEN)
ORANGE (CD-ORANGE)
Privacy Flap connects with hook and loop attachment between the seat and back support for added privacy.
$33.33PRIVACY FLAP (CD-PF-CV)
8 PRIVACY FLAP (OPTIONAL)
COLOR LOCATION
$0.00THREAD COLOR OPTIONS
RED (CD-EMB-RED)
PURPLE (CD-EMB-PURPLE)
PINK (CD-EMB-PINK)
BLUE (CD-EMB-BLUE)
GREEN (CD-EMB-GREEN)
SILVER (CD-EMB-SILVER)
FONT STYLE OPTIONS
Helvetica (CD-EMB-HELVETICA)
Garamond (CD-EMB-GARAMOND)
(CD-EMB-TWILIGHT)
(CD-EMB-SCRIPT)
WORD ONE
WORD TWO
A. B.
9 EMBROIDERY (OPTIONAL)
$0.00
10 SINGLE LATERAL DEPTH$0.00LATERAL DEPTH
OMIT LEFT (CD-DEEP-LAT-L-OMIT)
OMIT RIGHT (CD-DEEP-LAT-R-OMIT)
3” D x 5” L LEFT (CD-DEEP-LAT-L-3)
3” D x 5” L RIGHT (CD-DEEP-LAT-R-3)
5” D x 6” L LEFT (CD-DEEP-LAT-L-5)
5” D x 6” L RIGHT (CD-DEEP-LAT-R-5)
7” D x 7” L LEFT (CD-DEEP-LAT-L-7)
7” D x 7” L RIGHT (CD-DEEP-LAT-R-7)
Laterals are mounted at a fixed height position. Laterals are width and angle adjustable. Lateral pad height changes with different depth selections. If specific wing height location is needed, please indicate in the notes below.
7” 7”5” 5” 7”
22”
9” 11” 12” 13” 13”
7”
14”
18” L Back Support
EXAMPLE
CD-ACTA-BACK-DEEP-SHORTFORMREV0218
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*Length (L) refers to the actual size dimension of the support from bottom to top edge.
6 HARDWARE OPTIONS
Quick Release and Fixed hardware are fully adjustable for height, depth, width and angle of recline. Fixed requires tools for removal and is designed to provide extra support for users with tone and for back supports greater than 24” wide. Compass® 4 hardware may be installed on 3/4”, 7/8”, 1” and 1 1/8” tubing.
COMPASS® 4 MOUNTING HARDWARECompass® Power Mount Bracket is height adjustable up to 8” in 1/2” increments, but may be limited by the chair. Release levers allow for easy installation, removal and height adjustment of the back support. Not available on back supports smaller than 12”L or 12” W, or sizes 12Wx16L & 12Wx18L
QUANTUM with TRU BALANCE 3
PERMOBIL with CORPUS 3G
QUICKIE with 3.7 POWER
AVID REHAB with POWER T & R
ROVI with MOTION CONCEPTS*
(CD-PMB-QUANTUM)
(CD-PMB-PERMOBIL)
(CD-PMB-QUICKIE)
(CD-PMB-AVID)
(CD-PMB-ROVI)
$500.00
$500.00
$500.00
$500.00
$500.00
*Using Compass® Power Mount on Rovi requires mounting to the RECESSED PLANAR INTERFACE PLATE available when ordering the Motion Concepts Seating System. Drilling is required for mounting.
COMPASS® POWER MOUNT BRACKET
REMOVE (CD-REMOVE)
A. PREMIUM PAD SIZE
6Wx3LSOFT BL-HSP1-6W3L
EXTRA SOFT BL-HSP2-6W3L
8W x 4LSOFT BL-HSP1-8W4L
EXTRA SOFT BL-HSP2-8W4L
Adjustable Wing 10W x 5L
SOFT BL-HSP1-10W5L
EXTRA SOFT BL-HSP2-10W5L
Adjustable Wing 12W x 5L
SOFT BL-HSP1-12W5L
EXTRA SOFT BL-HSP2-12W5L
Adjustable Wing 14W x 5L
SOFT BL-HSP1-14W5L
EXTRA SOFT BL-HSP2-14W5L
Adjustable Wing 18W x 5L
SOFT BL-HSP1-18W5L
EXTRA SOFT BL-HSP2-18W5L
A1. PREMIUM PAD COVER MATERIAL
GlideWear® provides skin protection and shear reduction. Not fluid resistant. GLIDEWEAR® GLIDEWEAR (ADD $25.00)
Comfort-Tek™ provides fluid protection and is an easily cleaned surface. COMFORT-TEK™ COMFORT-TEK
Stretch-Air™ provides air transmission and heat dissipation. STRETCH-AIR™ STRETCH-AIR
L
W
Make a selection in sections A -or- B.
B1. BASIC PAD COVER MATERIAL
Comfort-Tek™ provides fluid protection and is an easily cleaned surface. COMFORT-TEK™ COMFORT-TEK
Stretch-Air™ provides air transmission and heat dissipation. STRETCH-AIR™ STRETCH-AIR
L
W
$125.00/EA$230.00/EA
11 BODILINK® HEAD SUPPORT PAD STYLEHCPCS Code: E0955
*Length (L) refers to the actual size dimension of the support from bottom to top edge.
B. BASIC PAD SIZE
6Wx5L BL-HSP3-6W3L
8W x 5L BL-HSP3-8W5L
10W x 6L BL-HSP3-10W6L
12W x 6L BL-HSP3-12W6L
14W x 6L BL-HSP3-14W6L
18W x 6L BL-HSP3-18W6L
NOTES
CD-ACTA-BACK-DEEP-SHORTFORMREV0218
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12 BODILINK® HEAD SUPPORT HARDWAREHCPCS Code: E1028