VISCO BACK ORDER FORM - d37xlajmpyyml6.cloudfront.netd37xlajmpyyml6.cloudfront.net/standard_order_forms/Visco Back Order 0418.pdf · visco-back® order form patient reference: page

SIZE SELECTION1

LEN

GTH

*

FRAME WIDTH

16”

18”

20”

16” 18” 20” 22”

14”

24”

22”

VISCO BACK®

ORDER FORMHCPCS CODING: E2611/E2612

GENERAL USE BACK

Company Name/ACCT #:

P.O. Number:

Requested By:

Phone: Fax:

Email:

Ship To:

Patient Reference:

$453.00 $530.00

Shown with Compass® 4 Quick Release 2 Point Hardware.

*Length (L) refers to the actual size dimension of the support from bottom to top edge.

BASE MSRP BY SIZE

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LEN

GTH

*

FRAME WIDTH

16W22L 18W22L 20W22L 22W22L

16W20L 18W20L 20W20L 22W20L

16W18L 18W18L 20W18L 22W18L

16W16L 18W16L 20W16L 22W16L

16W14L 18W14L 20W14L

24W22L

24W20L

24W18L

16”

18”

20”

16” 18” 20” 22”

14”

24”

22”

2 POINT Mounting Hardware Only 4 POINT Only

VB-BSSizes available are subject to hardware being used. IF DESIRED SIZE IS NOT LISTED, PLEASE CONTACT

CUSTOMER SERVICE FOR ASSISTANCE. | 800.564.9248

VISCO-BACK® ORDER FORM Patient Reference: PAGE 1 of 6

Required

COVER & HARDWARE SELECTION2 Required

2.1 COVER SELECTIONMSRP $0.00

Both fabrics are latex-free. Fabric selection is for the support surface only. Other fabrics used in cover construction remain the same.

COMFORT-TEK™ Cover(COMFORT-TEK)

STRETCH-AIR™ Cover (STRETCH-AIR)

QUICK RELEASE 2 POINT (Q-COMPASS)

QUICK RELEASE 4 POINT(Q-COMPASS4)

COMFORT-TEK™ is a smooth, easily cleaned surface. The fluid

protection aids in infection control.

STRETCH-AIR™ has comfortable stretch, air transmission and heat dissipation. It is not fluid resistant.

Please fill in the above with dimensions from the size chart to the right.Example Part: VB-BS16W18L

2.2 HARDWARE SELECTIONMSRP $0.00

COMPASS® 4 QUICK RELEASE

4 POINTTOP VIEW

FOR 16W-22W FOR 24W

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.


BACK SUPPORT ADD-ON SELECTIONS3 Optional

3.1 3.2 3.3COLOR EMBROIDERY PRIVACY FLAPMSRP $26.00 MSRP $26.00 MSRP $37.00

This flap connects with hook & loop attachment between the seat and back for added privacy.

Privacy Flap

Color Location

RED (RED)

PURPLE (PURPLE)

PINK (PINK)

BLUE (BLUE)

GREEN (GREEN)

ORANGE (ORANGE)

REMOVE (REMOVE)

PRIVACY FLAP (PV-FLAP)

A. THREAD COLOR OPTIONS

RED (EMB-RED) BLUE (EMB-BLUE)

PURPLE (EMB-PURPLE) GREEN (EMB-GREEN)

PINK (EMB-PINK) SILVER (EMB-SILVER)

B. FONT OPTIONS

Helvetica (EMB-Helvetica) (EMB-Twilight)

Garamond (EMB-Garamond) (EMB-Script)

C. WORD ONE

WORD TWO (optional)

*ADDITIONAL LEAD TIMES MAY APPLY

Accent colors are applied via colored piping. Placement of the piping may vary by back support size and mounting hardware. If no colors are selected, our standard silver reflective piping is used at no additional cost.

BODILINK® LATERAL TRUNK SUPPORT & HARDWARE4

Contact Customer Support for custom sizes. 1.800.564.9248.

Continue on next page for cover selection (section 4.3) if basic style pads are selected.

• You may make one selection per column (Left, Extra Left, Right, and Extra Right) in section 4.1.• Follow each column down to sections 4.2 and 4.3 (next page) and select a style and cover for each pad selected in section 4.1. Premium pads in section 4.4 on next page.

4.1

4.2

BASIC PAD SIZE & SHAPE

BASIC PAD STYLE

HCPCS Code: E0956 MSRP $82.00/ea.

MSRP $0.00/ea.

*Length (L) refers to the actual size dimension of the support from top to bottom edge. Depth (D) refers to the actual size dimension from anterior to posterior edge.

SHAPE SIZE LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT

SUP

PO

RTI

VE

3”L x 4”D BL-LTSP1S-3L4D-LH BL-LTSP1S-3L4D-LH BL-LTSP1S-3L4D-RH BL-LTSP1S-3L4D-RH






AC

TIV

E

3”L x 4”D BL-LTSP1A-3L4D-LH BL-LTSP1A-3L4D-LH BL-LTSP1A-3L4D-RH BL-LTSP1A-3L4D-RH






STYLE OPTIONS LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT

MOLDABLE LTS-P1-MOLD LTS-P1-MOLD LTS-P1-MOLD LTS-P1-MOLD

RIGID LTS-P1-RIGID LTS-P1-RIGID LTS-P1-RIGID LTS-P1-RIGID

ACTIVE

SUPPORTIVE

OR

OR

OR

L

L

D

D

RIGIDMOLDABLE

*”EXTRA” parts may not fit depending on back support, pad, and hardware size and style combinations. Please contact customer support with questions.

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4.3 BASIC PAD COVERMSRP $0.00/ea.

COVER OPTIONS LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT

COMFORT-TEK™ LTS-P1-COMFORT LTS-P1-COMFORT LTS-P1-COMFORT LTS-P1-COMFORT

STRETCH-AIR™ LTS-P1-STRETCH LTS-P1-STRETCH LTS-P1-STRETCH LTS-P1-STRETCHOR

STRETCH-AIR™COMFORT-TEK™FOR AIR TRANSMISSION

& HEAT DISSIPATION.FOR FLUID PROTECTION & AN

EASILY CLEANED SURFACE.

• You may make one selection per column (Left, Extra Left, Right, and Extra Right) in section 4.4.• Follow each column down to sections 4.5 and 4.6 and select a style and cover for each pad selected in section 4.4.

4.4

4.5

4.6

PREMIUM PAD SIZE & SHAPE

PREMIUM PAD STYLE

PREMIUM PAD COVER

HCPCS Code: E0956 MSRP $88.00/ea.

MSRP $0.00/ea.

*Length (L) refers to the dimension of the support from top to bottom edge. Depth (D) refers to the dimension of the support from anterior to posterior edge.

SHAPE SIZE LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT

SUP

PO

RTI

VE


3”L x 5.5”D BL-LTSP2S-3L5D-LH BL-LTSP2S-3L5D-LH BL-LTSP2S-3L5D-RH BL-LTSP2S-3L5D-RH





AC

TIV

E


3”L x 5.5”D BL-LTSP2A-3L5D-LH BL-LTSP2A-3L5D-LH BL-LTSP2A-3L5D-RH BL-LTSP2A-3L5D-RH





COVER OPTIONS MSRP LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT

NO COVER $0.00/ea. LTS-P2-NO-CV LTS-P2-NO-CV LTS-P2-NO-CV LTS-P2-NO-CV

COMFORT-TEK™ $0.00/ea. LTS-P2-COMFORT LTS-P2-COMFORT LTS-P2-COMFORT LTS-P2-COMFORT

STRETCH-AIR™ $0.00/ea. LTS-P2-STRETCH LTS-P2-STRETCH LTS-P2-STRETCH LTS-P2-STRETCH

GLIDEWEAR® $13.00/ea. LTS-P2-GLIDE LTS-P2-GLIDE LTS-P2-GLIDE LTS-P2-GLIDE

COMFORT-TEK™ with FOAM $13.00/ea. LTS-P2-COMFORT-FM LTS-P2-COMFORT-FM LTS-P2-COMFORT-FM LTS-P2-COMFORT-FM

STRETCH-AIR™ with FOAM $13.00/ea. LTS-P2-STRETCH-FM LTS-P2-STRETCH-FM LTS-P2-STRETCH-FM LTS-P2-STRETCH-FM

GLIDEWEAR® with FOAM $26.00/ea. LTS-P2-GLIDE-FM LTS-P2-GLIDE-FM LTS-P2-GLIDE-FM LTS-P2-GLIDE-FM

STYLE OPTIONS LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT

MOLDABLE LTS-P2-MOLD LTS-P2-MOLD LTS-P2-MOLD LTS-P2-MOLD

RIGID LTS-P2-RIGID LTS-P2-RIGID LTS-P2-RIGID LTS-P2-RIGID

SUPPORTIVE

ACTIVE

OR

OR

OR

FOR SKIN PROTECTION & SHEAR REDUCTION. NOT FLUID RESISTANT.

STRETCH-AIR™ COVER with FOAMCOMFORT-TEK™FOR AIR TRANSMISSION

& HEAT DISSIPATION.

FOR SOFT FEEL, NON-ZERO CUSHIONING SUPPORT.

FOR FLUID PROTECTION & AN EASILY CLEANED SURFACE.

L

L

D

D

RIGIDMOLDABLE

*”EXTRA” parts may not fit depending on back support, pad, and hardware size and style combinations. Please contact customer support with questions.


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Both Fixed and Swing-Away hardware styles are adjustable.

4.7 GTMOUNTING HARDWARE

SLOT MOUNTING MSRP LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT

SWING-AWAY HCPCS Code: E1028

$271.00/ea. BL-LTS-GT1SAS-LH BL-LTS-GT1SAS-LH BL-LTS-GT1SAS-RH BL-LTS-GT1SAS-RH

FIXED $129.00/ea. BL-LTS-GT1FXS-LH BL-LTS-GT1FXS-LH BL-LTS-GT1FXS-RH BL-LTS-GT1FXS-RH

SLOT MOUNTING MSRP LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT

SWING-AWAY HCPCS Code: E1028

$298.00/ea. BL-LTS-GT2SAS-LH BL-LTS-GT2SAS-LH BL-LTS-GT2SAS-RH BL-LTS-GT2SAS-RH

FIXED $178.00/ea. BL-LTS-GT2FXS-LH BL-LTS-GT2FXS-LH BL-LTS-GT2FXS-RH BL-LTS-GT2FXS-RH

**TRACK MOUNTING MSRP LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT

SWING-AWAYHCPCS Code: E1028

$298.00/ea. BL-LTS-GT2SAT-LH BL-LTS-GT2SATX-LH BL-LTS-GT2SAT-RH BL-LTS-GT2SATX-RH

FIXED $178.00/ea. BL-LTS-GT2FXT-LH BL-LTS-GT2FXTX-LH BL-LTS-GT2FXT-RH BL-LTS-GT2FXTX-RH

OR

OR

OR

4.8 GT ADDITIONAL OPTIONS

HARDWARE COVER LEFT *EXTRA LEFT RIGHT EXTRA RIGHT

MSRP $26.00/ea BL-LTS-HCOVER BL-LTS-HCOVER BL-LTS-HCOVER BL-LTS-HCOVER

EXTRA HARDWARE LINKS LEFT ADD’L LEFT RIGHT ADD’L RIGHT

MSRP $37.00/link BL-LTS-GT1LINK BL-LTS-GT1LINK BL-LTS-GT1LINK BL-LTS-GT1LINK

1”

SWING-AWAY FIXED

Open Position

Release Button

• You may make one selection per column (Left, Extra Left, Right, and Extra Right) in section 4.7.

• GT and GT2 Hardware and Pad styles are interchangeable. • GT hardware extra links (section 4.8) will only work with GT style hardware.

*”EXTRA” parts may not fit depending on back support, pad, and hardware size and style combinations.

Both Fixed and Swing-Away hardware styles are adjustable.

4.9GT2MOUNTING HARDWARE

4.10 GT2 ADDITIONAL OPTIONS

HARDWARE COVER LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT

MSRP $26.00/ea BL-LTS-HCOVER BL-LTS-HCOVER BL-LTS-HCOVER BL-LTS-HCOVER

LONG MOUNTING BRACKET LEFT *EXTRA LEFT RIGHT *EXTRA RIGHT

For Slot Mount MSRP $37.00/ea BL-LTS-GT2LSLOT-LH BL-LTS-GT2LSLOT-LH BL-LTS-GT2LSLOT-RH BL-LTS-GT2LSLOT-RH

EXTRA HARDWARE LINKS LEFT ADD’L LEFT RIGHT ADD’L RIGHT

MSRP $37.00/link BL-LTS-GT2LINK BL-LTS-GT2LINK BL-LTS-GT2LINK BL-LTS-GT2LINK

1¼”

adds 1” of adjustment per bracket

SLOT MOUNT **TRACK MOUNT

Swing-Away ShownSwing-Away Shown

Fixed Shown

Open Position

Release Button

Release Button

• You may make one selection per column in section 4.9.

**TRACK MOUNT is suggested since it allows for extra mounting/adjustment space when using Compass® 4 Hardware.

• “Extra” Track Mount Hardware does not come with an extra track

• Extra links and long mounting bracket (section 4.10) only for GT2 hardware.

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14W x 5L Head Support Pad Pictured

BODILINK® HEAD SUPPORT HARDWARE & PADS5

COMFORT-TEK FOR FLUID PROTECTION & AN EASILY CLEANED

SURFACE.

FOR AIR TRANSMISSION & HEAT DISSIPATION.

STRETCH-AIR

FOR SKIN PROTECTION & SHEAR REDUCTION. NOT FLUID RESISTANT.

L

5.2 PREMIUM PAD COVER MATERIAL

GlideWear® (GLIDEWEAR) (add $26.00)

Comfort-Tek (COMFORT-TEK)

Stretch-Air (STRETCH-AIR)

Length (L) refers to the actual size dimension of the support from bottom to top edge.

PREMIUM PAD SIZE HCPCS CODING: E0955 MSRP $237.00

5.1

Premium Head Support Pads angles can be

formed by adjusting the plates in the pad.

• You may make one selection per column.• Choose between premium (5.1) -or- basic (5.3).• Choose a cover material in 5.2 -or- 5.4.

6W x 3LSoft BL-HSP1-6W3L

Extra Soft BL-HSP2-6W3L

8W x 4LSoft BL-HSP1-8W4L


10W x 5Lwith adjustable wings

Soft BL-HSP1-10W5L



Soft BL-HSP1-12W5L



Soft BL-HSP1-14W5L



Soft BL-HSP1-18W5L


W

W

Pad Firmness

L

L

L

L

L

COMFORT-TEK FOR FLUID PROTECTION & AN EASILY CLEANED

SURFACE.

FOR AIR TRANSMISSION & HEAT DISSIPATION.

STRETCH-AIR

5.4 BASIC PAD COVER MATERIAL

Comfort-Tek (COMFORT-TEK)

Stretch-Air (STRETCH-AIR)

Basic head support pads can be formed

to any shape using the moldable steel insert

inside the pad.

BASIC PAD SIZE HCPCS CODING: E0955 MSRP $129.00

5.3

6W x 5L BL-HSP3-6W5L






L

L

L

L

L

L

W

W

Length (L) refers to the actual size dimension of the support from bottom to top edge.

5.5 HEAD SUPPORT HARDWAREHCPCS CODING: E1028

SIZE & SHAPE MSRP PART NUMBER

MID 6 $223.00 (BL-HS-PT1RMMID6)

LAT 6 $260.00 (BL-HS-PT1RMLAT6)

MID 8 $223.00 (BL-HS-PT1RMMID8)

LAT 8 $260.00 (BL-HS-PT1RMLAT8)

MAX 8* $327.00 (BL-HS-PT1RMMAX8)

*Provides the greatest amount of articulation and range of motion.

PT HARDWARE, REMOVABLEA.

PT

HA

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ID 6

PT

HA

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AT

6

PT

HA

RD

WA

RE

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ID 8

PT

HA

RD

WA

RE

, L

AT

8

PT

HA

RD

WA

RE

, M

AX

8

• You may make one selection per column in either A -or- B.• If choosing 5.5 A, choose a stem length option next.• Choose which mounting block option you require in 5.6.

PT MODEL

TOTAL # OF

LINKS

TOTAL LINK

LENGTH

MAX. ANTERIOR

REACH

MAX. POSTERIOR

REACH

MAX. LATERAL REACH

MID 6 2 6” 5.5” 1” N/A

LAT 6 3 6” 5.5” 1” 6”

MID 8 2 8” 7.5” 1” N/A

LAT 8 3 8” 7.5” 1” 8”

MAX 8 4 8” 7.5” 3” 8”

PT HARDWARE RANGE OF MOTION

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SUBMIT BY EMAIL

PT HARDWARE, REMOVABLE (CONTINUED)

STEM LENGTH MSRP PART NUMBER

STANDARD 7” STEM $0.00 (HS-STEM-7)

**3” STEM $0.00 (HS-STEM-3)

PT HARDWARE, STEM LENGTH OPTION

ST

AN

DA

RD

PT

ST

EM

, 7

”

PT

ST

EM

, 3

”

SIZE & SHAPE MSRP PART NUMBER

LATERAL $228.00 (BL-HS-GT3RMLAT)

MID-LINE $191.00 (BL-HS-GT3RMMID)

GT HARDWARE, REMOVABLEB.

GT

HA

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AL

GT

HA

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INE

GT MODEL

TOTAL # OF

LINKS

TOTAL LINK

LENGTH

MAX. ANTERIOR

REACH

MAX. POSTERIOR

REACH

MAX. LATERAL REACH

LAT 5 10.5” 10” 2” 7.5”

MID 3 8.5” 8” 2” N/A

GT HARDWARE RANGE OF MOTION

MOUNTING BLOCK OR BRACKET MSRP PART NUMBER

POSTERIOR A MOUNTING BLOCK $0.00 (HS-MB-POSTA)MOUNTING BLOCK-

POSTERIOR A

5.6 HEAD SUPPORT MOUNTING OPTION

5.7 EXTRA HARDWARE

LINK LENGTH MSRP EXTRA PART

*EXTRA 2” LINK $57.00 (BL-HS-PT1LINK2)



TOOL-LESS WING LOCK MSRP EXTRA PART EXTRA PART EXTRA PART EXTRA PART

*1 LOCK $21.00/each (BL-HS-52WINGA1) (BL-HS-52WINGA1) (BL-HS-52WINGA1) (BL-HS-52WINGA1)

*FOR PT HARDWARE ONLY

ADDITIONAL MSRP EXTRA PART

1/4” SPACER PLATE $37.00/each (BL-HS-SPCRA)

**3” Stem is recommended for use with power mounting where there may be special constraints with power chair functions

VISCO BACK ORDER FORM - d37xlajmpyyml6.cloudfront.netd37xlajmpyyml6.cloudfront.net/standard_order_forms/Visco Back Order 0418.pdf · visco-back® order form patient reference: page

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