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SIZE SELECTION 1 LENGTH* FRAME WIDTH 16” 18” 20” 16” 18” 20” 22” 14” 24” 22” VISCO BACK ® ORDER FORM HCPCS CODING: E2611/E2612 GENERAL USE BACK Company Name/ACCT #: P.O. Number: Requested By: Phone: Fax: Email: Ship To: Patient Reference: $514.00 $590.00 $439.00 $514.00 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 VISCO-BACK-ORDER REV0316 LENGTH* 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-BS Sizes 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 4 Required COVER & HARDWARE SELECTION 2 Required 2.1 COVER SELECTION MSRP $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-TEKis a smooth, easily cleaned surface. The fluid protection aids in infection control. STRETCH-AIRhas 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 SELECTION MSRP $0.00 COMPASS ® 4 QUICK RELEASE 4 POINT TOP 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 customerservice@comfortcompany.com or 1.406.522.8563.
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VISCO BACK ORDER FORM - d37xlajmpyyml6.cloudfront.netd37xlajmpyyml6.cloudfront.net/standard_order_forms/Visco-Back.pdf · visco-back® order form patient reference: page 3 of 4 5

Sep 20, 2019

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  • 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:

    $514.00 $590.00

    $439.00 $514.00

    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

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    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 4

    Required

    COVER & HARDWARE SELECTION2 Required2.1 COVER SELECTION

    MSRP $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 customerservice@comfortcompany.com or 1.406.522.8563.

  • VISCO-BACK® ORDER FORM Patient Reference: PAGE 2 of 4

    BACK SUPPORT ADD-ON SELECTIONS3 Optional

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    3.1 3.2 3.3COLOR EMBROIDERY PRIVACY FLAPMSRP $25.00 MSRP $25.00 MSRP $35.00

    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.

    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)

    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

    LATERAL TRUNK SUPPORT & HARDWARE4 Optional4.1 LATERAL TRUNK SUPPORT PAD STYLE

    Select a left and/or right lateral trunk support pad using any combination of size, style and fabric.

    STRETCH-AIR™

    COMFORT-TEK™

    has comfortable stretch, air transmission and heat

    dissipation.

    is a smooth, easily cleaned surface. The fluid protection

    aids in infection control.

    Contact Customer Service for custom sizes that are not listed below. 1.800.564.9248.HCPCS Code: E0956 MSRP $79.00/ea.

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

    L

    D

    L

    D

    L

    D

    L

    D

    MOLDABLE

    RIGID

    MOLDABLE ACTIVE

    RIGID ACTIVE

    4”D x 3”L 5”D x 3”L 5”D x 4”L 6”D x 4”L 6”D x 6”L 7”D x 5”L

    COMFORT-TEK LT1-MF4W3T LT1-MF5W3T LT1-MF5W4T LT1-MF6W4T LT1-MF6W6T LT1-MF7W5T

    Left Right Left Right Left Right Left Right Left Right Left Right

    Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right

    STRETCH-AIR LT1-MS4W3T LT1-MS5W3T LT1-MS5W4T LT1-MS6W4T LT1-MS6W6T LT1-MS7W5T

    Left Right Left Right Left Right Left Right Left Right Left Right

    Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right

    COMFORT-TEK LT1-MF4W3T-AL LT1-MF4W3T-AR LT1-MF5W3T-AL LT1-MF5W3T-AR LT1-MF5W4T-AL LT1-MF5W4T-AR LT1-MF6W4T-AL LT1-MF6W4T-AR LT1-MF6W6T-AL LT1-MF6W6T-AR LT1-MF7W5T-AL LT1-MF7W5T-AR

    Left Right Left Right Left Right Left Right Left Right Left Right

    Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right

    STRETCH-AIR LT1-MS4W3T-AL LT1-MS4W3T-AR LT1-MS5W3T-AL LT1-MS5W3T-AR LT1-MS5W4T-AL LT1-MS5W4T-AR LT1-MS6W4T-AL LT1-MS6W4T-AR LT1-MS6W6T-AL LT1-MS6W6T-AR LT1-MS7W5T-AL LT1-MS7W5T-AR

    Left Right Left Right Left Right Left Right Left Right Left Right

    Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right

    COMFORT-TEK LT1-RF4W3T LT1-RF5W3T LT1-RF5W4T LT1-RF6W4T LT1-RF6W6T LT1-RF7W5T

    Left Right Left Right Left Right Left Right Left Right Left Right

    Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right

    STRETCH-AIR LT1-RS4W3T LT1-RS5W3T LT1-RS5W4T LT1-RS6W4T LT1-RS6W6T LT1-RS7W5T

    Left Right Left Right Left Right Left Right Left Right Left Right

    Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right

    COMFORT-TEK LT1-RF4W3T-AL LT1-RF4W3T-AR LT1-RF5W3T-AL LT1-RF5W3T-AR LT1-RF5W4T-AL LT1-RF5W4T-AR LT1-RF6W4T-AL LT1-RF6W4T-AR LT1-RF6W6T-AL LT1-RF6W6T-AR LT1-RF7W5T-AL LT1-RF7W5T-AR

    Left Right Left Right Left Right Left Right Left Right Left Right

    Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right

    STRETCH-AIR LT1-RS4W3T-AL LT1-RS4W3T-AR LT1-RS5W3T-AL LT1-RS5W3T-AR LT1-RS5W4T-AL LT1-RS5W4T-AR LT1-RS6W4T-AL LT1-RS6W4T-AR LT1-RS6W6T-AL LT1-RS6W6T-AR LT1-RS7W5T-AL LT1-RS7W5T-AR

    Left Right Left Right Left Right Left Right Left Right Left Right

    Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right

  • VISCO-BACK® ORDER FORM Patient Reference: PAGE 3 of 4

    BODILINK HEAD SUPPORT & HARDWARE5 Optional

    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

    L

    L

    L

    L

    W

    W

    5.2 PAD COVER MATERIAL

    GlideWear® (GLIDEWEAR)

    Comfort-Tek (COMFORT-TEK)

    Stretch-Air (STRETCH-AIR)

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

    HEAD SUPPORT PAD STYLEHCPCS CODING: E0955 MSRP $230.00

    5.1

    Pad Firmness

    6W x 3½LSoft BL-HSP1-6W3L

    Extra Soft BL-HSP2-6W3L

    8W x 4LSoft BL-HSP1-8W4L

    Extra Soft BL-HSP2-8W4L

    10W x 5Lwith adjustable wings

    Soft BL-HSP1-10W5L

    Extra Soft BL-HSP2-10W5L

    14W x 5Lwith adjustable wings

    Soft BL-HSP1-14W5L

    Extra Soft BL-HSP2-14W5L

    18W x 5Lwith adjustable wings

    Soft BL-HSP1-18W5L

    Extra Soft BL-HSP2-18W5L

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    EXTRA LINKSMSRP $35.00/link

    LATERAL TRUNK SUPPORT & HARDWARE4 Optional ContinuedPROTECTIVE COVER (OPTIONAL)4.2

    A) B)

    4.3

    RIGIDHCPCS Code: E0956

    MSRP $125.00/bracket

    SWING AWAYHCPCS Code: E1028

    MSRP $263.00/ea

    PROTECTIVE LATERAL HARDWARE COVER

    MSRP $19.00/ea

    Select a set of hardware below (Section A). Extra links (Section B) may be selected to add 1” of additional depth and adjustability.

    CLOSED OPEN

    3” 3”1”

    EXTRA LINK

    LATERAL TRUNK SUPPORT HARDWARE

    LTL-SF LTR-SF LTL-RF LTR-RF LEFT LT1-LINK RIGHT LT1-LINK LT1-PROTECT2

    Left Right Left Right 1 Extra Link 1 Extra Link Left Right

    Extra Left Extra Right Extra Left Extra Right 2 Extra Links 2 Extra Links Extra Left Extra Right

    3 Extra Links 3 Extra Links

    4 Extra Links 4 Extra Links

    Both hardware styles in Section A are width adjustable. Cover wraps around hardware and closes with hook and loop attachment.

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    VISCO-BACK® ORDER FORM Patient Reference: PAGE 4 of 4

    BODILINK HEAD SUPPORT & HARDWARE5 Optional

    Extra Link

    Extra Spacer Plate

    ¼”

    5.3 HEAD SUPPORT HARDWAREHCPCS CODING: E1028

    MSRP $221.00/ea. MSRP $35.00/extra link or spacer each

    Removable Hardware (BL-HSH-FX)

    Extra Link (BL-HSH-LINK)

    Extra Spacer Plate (BL-HSH-SPCR)

    3 ¼”

    Continued

    SUBMIT BY EMAIL

    Text Field 2: Text Field 3: Text Field 4: Text Field 5: Text Field 6: Text Field 7: Text Field 8: Text Field 9: Text Field 10: Check Box 1: OffCheck Box 2: OffCheck Box 3: OffCheck Box 4: OffText Field 11: Check Box 5: OffCheck Box 6: OffCheck Box 7: OffCheck Box 8: OffCheck Box 9: OffCheck Box 10: OffCheck Box 11: OffCheck Box 12: OffCheck Box 13: OffCheck Box 14: OffCheck Box 15: OffCheck Box 16: OffCheck Box 17: OffCheck Box 18: OffCheck Box 19: OffCheck Box 20: OffText Field 12: Text Field 13: Check Box 21: OffCheck Box 22: OffCheck Box 23: OffCheck Box 24: OffCheck Box 25: OffCheck Box 26: OffCheck Box 27: OffCheck Box 28: OffCheck Box 29: OffCheck Box 30: OffCheck Box 31: OffCheck Box 32: OffCheck Box 33: OffCheck Box 34: OffCheck Box 35: OffCheck Box 36: OffCheck Box 37: OffCheck Box 38: OffCheck Box 39: OffCheck Box 40: OffCheck Box 41: OffCheck Box 42: OffCheck Box 43: OffCheck Box 44: OffCheck Box 45: OffCheck Box 46: OffCheck Box 47: OffCheck Box 48: OffCheck Box 49: OffCheck Box 50: OffCheck Box 51: OffCheck Box 52: OffCheck Box 53: OffCheck Box 54: OffCheck Box 55: OffCheck Box 56: OffCheck Box 57: OffCheck Box 58: OffCheck Box 59: OffCheck Box 60: OffCheck Box 61: OffCheck Box 62: OffCheck Box 63: OffCheck Box 64: OffCheck Box 65: OffCheck Box 66: OffCheck Box 67: OffCheck Box 68: OffCheck Box 69: OffCheck Box 70: OffCheck Box 71: OffCheck Box 72: OffCheck Box 73: OffCheck Box 74: OffCheck Box 75: OffCheck Box 76: OffCheck Box 77: OffCheck Box 78: OffCheck Box 79: OffCheck Box 80: OffCheck Box 81: OffCheck Box 82: OffCheck Box 83: OffCheck Box 84: OffCheck Box 85: OffCheck Box 86: OffCheck Box 87: OffCheck Box 88: OffCheck Box 89: OffCheck Box 90: OffCheck Box 91: OffCheck Box 92: OffCheck Box 93: OffCheck Box 94: OffCheck Box 95: OffCheck Box 96: OffCheck Box 97: OffCheck Box 98: OffCheck Box 99: OffCheck Box 100: OffCheck Box 101: OffCheck Box 102: OffCheck Box 103: OffCheck Box 104: OffCheck Box 105: OffCheck Box 301: OffCheck Box 302: OffCheck Box 303: OffCheck Box 304: OffCheck Box 305: OffCheck Box 306: OffCheck Box 307: OffCheck Box 308: OffCheck Box 309: OffCheck Box 3010: OffCheck Box 106: OffCheck Box 107: OffCheck Box 108: OffCheck Box 109: OffCheck Box 1010: OffCheck Box 1011: OffCheck Box 1012: OffCheck Box 1013: OffCheck Box 111: OffCheck Box 112: OffCheck Box 113: OffCheck Box 114: OffCheck Box 115: OffCheck Box 116: OffCheck Box 117: OffCheck Box 118: OffCheck Box 119: OffCheck Box 120: OffCheck Box 121: OffCheck Box 122: OffCheck Box 123: OffCheck Box 124: OffCheck Box 125: OffCheck Box 126: OffCheck Box 127: OffCheck Box 128: OffCheck Box 129: OffCheck Box 130: OffCheck Box 131: OffCheck Box 132: OffCheck Box 133: OffCheck Box 134: OffCheck Box 135: OffCheck Box 136: OffCheck Box 137: OffCheck Box 138: OffCheck Box 139: OffCheck Box 140: OffCheck Box 141: OffCheck Box 142: OffCheck Box 143: OffCheck Box 144: OffCheck Box 145: OffCheck Box 146: OffCheck Box 147: OffCheck Box 148: OffCheck Box 149: OffCheck Box 150: OffCheck Box 151: OffCheck Box 152: OffCheck Box 153: OffCheck Box 154: OffCheck Box 155: OffCheck Box 156: OffCheck Box 157: OffCheck Box 158: OffCheck Box 159: OffCheck Box 160: OffCheck Box 161: OffCheck Box 162: OffCheck Box 163: OffCheck Box 164: OffCheck Box 165: OffCheck Box 166: OffCheck Box 167: OffCheck Box 168: OffCheck Box 169: OffCheck Box 170: OffCheck Box 171: OffCheck Box 172: OffCheck Box 173: OffCheck Box 174: OffCheck Box 175: OffCheck Box 176: OffCheck Box 177: OffCheck Box 178: OffCheck Box 179: OffCheck Box 180: OffCheck Box 181: OffCheck Box 182: OffCheck Box 183: OffCheck Box 184: OffCheck Box 185: OffCheck Box 186: OffCheck Box 187: OffCheck Box 188: OffCheck Box 189: OffCheck Box 190: OffCheck Box 191: OffCheck Box 192: OffCheck Box 401: OffCheck Box 402: OffCheck Box 403: OffCheck Box 404: OffCheck Box 405: OffCheck Box 406: OffCheck Box 407: OffCheck Box 408: OffText Field 14: Check Box 409: OffCheck Box 4010: OffCheck Box 4011: OffCheck Box 4012: OffCheck Box 4013: OffCheck Box 4014: OffCheck Box 4015: OffCheck Box 4016: OffCheck Box 4017: OffCheck Box 4018: OffCheck Box 4019: OffCheck Box 4020: OffCheck Box 4021: OffCheck Box 4022: OffCheck Box 4023: OffCheck Box 4024: OffCheck Box 4025: OffCheck Box 4026: OffCheck Box 4027: OffCheck Box 4028: OffCheck Box 4029: OffCheck Box 4030: OffCheck Box 4031: OffCheck Box 4032: OffCheck Box 4033: OffCheck Box 4034: OffCheck Box 4035: OffCheck Box 4036: OffCheck Box 4037: OffCheck Box 4038: OffCheck Box 4039: OffCheck Box 4040: OffCheck Box 4041: OffText Field 15: Check Box 193: OffCheck Box 194: OffCheck Box 195: OffText Field 16: Submit 4: