CUSTOM ACTA-EMBRACE ™ BACK - SHORT ORDER FORM HCPCS CODE: E2617 1/3 1 BACK SUPPORT SIZE C - E - W H HCPCS Code: E2617 4 CUSTOM FOAM SELECTION Rear Layer Middle Layer Topper Layer A minimum of one layer must be chosen if Foam in Place is not selected in Section 4. A ¼” Crosslink foundation layer will come standard with foam selection. 5 FOAM IN PLACE KIT EXTRA SOFT MEMORY FOAM 1 BAG (CD-FIP3-1-XS) 1 1/2 BAG (CD-FIP3-1.5-XS) 3” BACK BORDER 1 BAG (CD-FIP4-1-XS) 1 1/2 BAG (CD-FIP4-1.5-XS) 4” BACK BORDER SOFT MEMORY FOAM 1 BAG (CD-FIP3-1-S) 1 1/2 BAG (CD-FIP3-1.5-S) 3” BACK BORDER 1 BAG (CD-FIP4-1-S) 1 1/2 BAG (CD-FIP4-1.5-S) 4” BACK BORDER MEDIUM MEMORY FOAM 1 BAG (CD-FIP3-1-M) 1 1/2 BAG (CD-FIP3-1.5-M) 3” BACK BORDER 1 BAG (CD-FIP4-1-M) 1 1/2 BAG (CD-FIP4-1.5-M) 4” BACK BORDER BAG POUR SIZE RECOMMENDATION CHART BORDER Thickness FRAME WIDTH RECOMMENDED BAG SIZE 3” 10”W-16”W 1 BAG 3” 17”W-22”W 1½ BAG 4” 10”W-14”W 1 BAG 4” 15”W-20”W 1½ BAG KIT INCLUDES: • Back cushion cover with optional 3” or 4” deep back with pleated surface to allow for foam growth. • Two aluminum stays which can be molded to support spinal curvature prior to pouring FIP chemicals. • 1” of Viscool medium foam is cut to the shape of back support and placed inside cover. • 1/2” Viscool soft foam is cut to the shape of back support and placed inside the cover in the front to smooth out any potential inconsistencies after pouring liquid foam. • Two plastic bags are included to contain the foam chemicals as they expand. (Note: Price of Viscool layers will be added to the order separately.) 3-4” Border Aluminum Stays Gap for Foam in Place Pleates 1” Viscool Medium ½” Viscool Soft $300.00 $400.00 $300.00 $400.00 $300.00 $400.00 $300.00 $400.00 $300.00 $400.00 $300.00 $400.00 Company Name/ACCT #: P.O. Number: Requested By: Phone: Fax: Email: Ship To: Patient Reference: 10-20” Width / 10-18” Length = $896 Base Price 21-24” Width / 10-18” Length = $984 Base Price 10-24” Width / 19-22” Length = $1012 Base Price 25-28” Width / 10-22” Length = $1453.33 Base Price $0.00 $0.00 $0.00 $0.00 *If desired size is not listed above, a 60% up charge will be applied for materials. 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) 1” (CD-TOP-VIS-XXS-1.00) SFC $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 2 COVER OPTIONS 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 Choose either Stretch-Air or Comfort-Tek cover fabric with Diamond or Digi-Camo accent fabric. Care for each accent fabric is identical. 3 MILITARY BRANCH PATCH ARMY (CD-ARMY-PATCH) AIR FORCE (CD-AIR-FORCE-PATCH) NAVY (CD-NAVY-PATCH) MARINES (CD-MARINES-PATCH) (OPTIONAL) CD-ACTA-EMBRACE-SHORTFORM REV0217 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. NOTE: Desired back support length is “H” dimension in part number above. Cover appearance may vary with hardware selection and size. 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. Standard foam layer thicknesses reduce to 3/8” on sizes 10-14L. SFC = Standard Foam Configuration. Use as a reference when choosing foam layers. = 1” (CD-TOP-VIS-XXS-1.00) SFC
Transcript
CUSTOM ACTA-EMBRACE™ BACK - SHORT ORDER FORM HCPCS CODE: E2617
1/3
1 BACK SUPPORT SIZE
C - E - W HHCPCS Code: E2617
4 CUSTOM FOAM SELECTION
Rear LayerMiddle Layer
Topper Layer
A minimum of one layer must be chosen if Foam in Place is not selected in Section 4. A ¼” Crosslink foundation layer will come standard with foam selection.
5 FOAM IN PLACE KIT
EXTRA SOFT MEMORY FOAM
1 BAG (CD-FIP3-1-XS)
1 1/2 BAG (CD-FIP3-1.5-XS)
3” BACK BORDER
1 BAG (CD-FIP4-1-XS)
1 1/2 BAG (CD-FIP4-1.5-XS)
4” BACK BORDER
SOFT MEMORY FOAM
1 BAG (CD-FIP3-1-S)
1 1/2 BAG (CD-FIP3-1.5-S)
3” BACK BORDER
1 BAG (CD-FIP4-1-S)
1 1/2 BAG (CD-FIP4-1.5-S)
4” BACK BORDER
MEDIUM MEMORY FOAM
1 BAG (CD-FIP3-1-M)
1 1/2 BAG (CD-FIP3-1.5-M)
3” BACK BORDER
1 BAG (CD-FIP4-1-M)
1 1/2 BAG (CD-FIP4-1.5-M)
4” BACK BORDER
BAG POUR SIZE RECOMMENDATION CHART
BORDERThickness
FRAME WIDTH
RECOMMENDED BAG SIZE
3” 10”W-16”W 1 BAG
3” 17”W-22”W 1½ BAG
4” 10”W-14”W 1 BAG
4” 15”W-20”W 1½ BAG
KIT INCLUDES: • Back cushion cover with optional 3” or 4” deep back with pleated surface to allow for foam growth.• Two aluminum stays which can be molded to support spinal curvature prior to pouring FIP chemicals.• 1” of Viscool medium foam is cut to the shape of back support and placed inside cover.• 1/2” Viscool soft foam is cut to the shape of back support and placed inside the cover in the front to smooth out any potential inconsistencies after pouring liquid foam.• Two plastic bags are included to contain the foam chemicals as they expand.(Note: Price of Viscool layers will be added to the order separately.)
3-4” Border
Aluminum Stays
Gap for Foam in Place
Pleates
1” Viscool Medium
½” Viscool Soft
$300.00$400.00
$300.00$400.00
$300.00$400.00
$300.00$400.00
$300.00$400.00
$300.00$400.00
Company Name/ACCT #:
P.O. Number:
Requested By:
Phone: Fax:
Email:
Ship To:
Patient Reference:
10-20” Width / 10-18” Length = $896 Base Price21-24” Width / 10-18” Length = $984 Base Price10-24” Width / 19-22” Length = $1012 Base Price25-28” Width / 10-22” Length = $1453.33 Base Price
$0.00 $0.00 $0.00 $0.00
*If desired size is not listed above, a 60% up charge will be applied for materials.
REAR LAYER (REQUIRED)
$0.00H.R. MEDIUM
1/4” (CD-REAR-HRM-0.25)
1/2” (CD-REAR-HRM-0.50)
3/4” (CD-REAR-HRM-0.75) SFC1” (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)
VISCOOLTM MEDIUM
1/2” (CD-REAR-VIS-M-0.50)
1” (CD-REAR-VIS-M-1.00)
VISCOOLTM SOFT
1/2” (CD-REAR-VIS-S-0.50)
1” (CD-REAR-VIS-S-1.00)
VISCOOLTM 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)
VISCOOLTM MEDIUM
1/2” (CD-MID-VIS-M-0.50)
1” (CD-MID-VIS-M-1.00)
VISCOOLTM SOFT
1/2” (CD-MID-VIS-S-0.50)
1” (CD-MID-VIS-S-1.00)
VISCOOLTM 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)
VISCOOLTM MEDIUM
1/2” (CD-TOP-VIS-M-0.50)
1” (CD-TOP-VIS-M-1.00)
VISCOOLTM SOFT
1/2” (CD-TOP-VIS-S-0.50)
1” (CD-TOP-VIS-S-1.00)
VISCOOLTM 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)
1” (CD-TOP-VIS-XXS-1.00) SFC
$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
2 COVER OPTIONS
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
Choose either Stretch-Air or Comfort-Tek cover fabric with Diamond or Digi-Camo accent fabric. Care for each accent fabric is identical.
3 MILITARY BRANCH PATCH ARMY(CD-ARMY-PATCH)
AIR FORCE(CD-AIR-FORCE-PATCH)
NAVY(CD-NAVY-PATCH)
MARINES(CD-MARINES-PATCH)
(OPTIONAL)
CD
-AC
TA-E
MB
RA
CE
-SH
OR
TFO
RM
R
EV
0217
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.
NOTE: Desired back support length is “H” dimension in part number above. Cover appearance may vary with hardware selection and size.
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.
Standard foam layer thicknesses reduce to 3/8” on sizes 10-14L.
SFC = Standard Foam Configuration. Use as a reference when choosing foam layers. =1” (CD-TOP-VIS-XXS-1.00) SFC
10”L - 12”L Back 5”L Wing13”L - 16”L Back 6”L Wing17”L - 22”L Back 8”L Wing
$0.00THREAD COLOR OPTIONS
Privacy Flap connects with hook and loop attachment between the seat and back support for added privacy.
$33.33PRIVACY FLAP (CD-PF-CV)
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.
12 PRIVACY FLAP (OPTIONAL)
10 EMBROIDERY (OPTIONAL)
$0.00
GROWTH KIT INCLUDES:• 2” or 4” growth plate that bolts onto the bottom of existing shell to grow the back support in length. • An additional 2” or 4” cushion and cover will be supplied based on selected growth plate.• All mounting hardware included in kit.
$333.332” GROWTH PLATE With ADD’L FOAM & COVER (CD-2”GK)
11 GROWTH KIT
$333.334” GROWTH PLATE With ADD’L FOAM & COVER (CD-4”GK)
Up to 1 1/2” wide webbing.$59.00EXTRA SMALL (CHG2-EB1)
13 STRAP EXTENSION GUIDE BRACKET (OPTIONAL)
Up to 2 1/4” wide webbing.$59.00SMALL (CHG2-EB2)
(OPTIONAL)
8 HARDWARE OPTIONS
Accent colors are applied via colored piping. If no color is selected, our standard reflective piping will be used.
2” or 4” Growth Plate
Cushion Foam
Privacy Flap
If multiple wings are needed, the extra wing will always be bottom mounted in the assembly process, and the initial wing always top mounted.
LEFTEXTRA LEFT WING LENGTH EXTRA RIGHT
5” L Linear Wing6” L Linear Wing8” L Linear Wing
(CD-ADD-L-WING-5-LIN)
RIGHT
(CD-ADD-L-WING-6-LIN)
(CD-ADD-L-WING-8-LIN)
(CD-ADD-R-WING-5-LIN)
(CD-ADD-R-WING-6-LIN)
(CD-ADD-R-WING-8-LIN)
(CD-LEFTWING-5-LIN)
(CD-LEFTWING-6-LIN)
(CD-LEFTWING-8-LIN)
(CD-RIGHTWING-5-LIN)
(CD-RIGHTWING-6-LIN)
(CD-RIGHTWING-8-LIN)
Bottom Mounted Top Mounted Bottom MountedTop Mounted
LINEAR HEIGHT/WIDTH ADJUSTABLE WING
CONTOURED HEIGHT/WIDTH ADJUSTABLE WING
$0.00Extra Wing $66.67
LEFTEXTRA LEFT WING HEIGHT EXTRA RIGHT
5” L Contoured Wing6” L Contoured Wing8” L Contoured Wing
(CD-ADD-L-WING-5-CON)
RIGHT
(CD-ADD-L-WING-6-CON)
(CD-ADD-L-WING-8-CON)
(CD-ADD-R-WING-5-CON)
(CD-ADD-R-WING-6-CON)
(CD-ADD-R-WING-8-CON)
(CD-LEFTWING-5-CON)
(CD-LEFTWING-6-CON)
(CD-LEFTWING-8-CON)
(CD-RIGHTWING-5-CON)
(CD-RIGHTWING-6-CON)
(CD-RIGHTWING-8-CON)
Bottom Mounted Top Mounted Bottom MountedTop Mounted
$0.00Extra Wing $66.67
Wing Length
Wing Length
COLOR LOCATION
- OR -
6 MOLDABLE ALUMINUM STAYSSPACE BETWEEN STAYS
1” (CD-STAY-1.0)
1 1/2” (CD-STAY-1.5)
$0.00
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)
NONE (CD-STAY-NONE)
SPECIFY CUSTOM SPACING(CD-STAY-OTHER)
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.
Aluminum Stay Pockets
Moldable Aluminum Stays
2/3CD-ACTA-EMBRACE-SHORTFORM REV0217
*Length (L) refers to the actual size dimension of the support from bottom to top edge.
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® 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.
QUANTUM with TRU BALANCE 3(CD-PMB-QUANTUM)
$500.00
PERMOBIL with CORPUS 3G(CD-PMB-PERMOBIL)
$500.00
QUICKIE with 3.7 POWER(CD-PMB-QUICKIE)
$500.00
AVID REHAB with POWER T & R(CD-PMB-AVID)
$500.00
ROVI with MOTION CONCEPTS*(CD-PMB-ROVI)
$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
provides skin protection and shear reduction. Not fluid resistant.
for fluid protection and an easily cleaned surface.
provides air transmission and heat dissipation.
15 LATERAL TRUNK SUPPORT HARDWARE
SWING AWAY (WIDTH ADJUSTABLE)
$263.00/EA
LEFT (LTL-SF)
1 ADD’L LEFT
A.
RIGHT (LTR-SF)
1 ADD’L RIGHT
ADDITIONAL LINKS (OPTIONAL)
$35.00/EA
1 ADD’L LEFT(LT1-LINK)
2 ADD’L LEFT
B.
1 ADD’L RIGHT(LT1-LINK)
2 ADD’L RIGHT
3 ADD’L LEFT
3 ADD’L RIGHT
3”
RIGID HARDWARE (WIDTH ADJUSTABLE)
$125.00/EA
LEFT (LTL-RF)
1 ADD’L LEFT
RIGHT (LTR-RF)
1 ADD’L RIGHT
1”
16 HARDWARE COVER (OPTIONAL)
PROTECTIVE LATERAL HARDWARE COVER
$19.00/EA
$221.00/EA
$35.00/EA
LEFT (LT1-PROTECT2)
1 ADD’L LEFT
1 ADD’L RIGHT
RIGHT(LT1-PROTECT2)
3”
17 BODILINK HEAD SUPPORT PAD STYLE 18 BODILINK HEAD SUPPORT PAD COVER CHOICE
19 HEAD SUPPORT HARDWARE
REMOVABLE HARDWARE
½” SHAFT (BL-HSH-FX)
¼” SPACER (BL-HSH-SPCR)
¼”
EXTRA SPACER PLATE
EXTRA SPACER PLATE
NOTES
14 LATERAL TRUNK SUPPORT PAD STYLEMOLDABLE STRETCH-AIR $79.00
SIZE
(LT1-MS4W3T)
(LT1-MS5W3T)
(LT1-MS5W4T)
(LT1-MS6W4T)
(LT1-MS6W6T)
(LT1-MS7W5T)
(LT1-MS4W3T)
(LT1-MS5W3T)
(LT1-MS5W4T)
(LT1-MS6W4T)
(LT1-MS6W6T)
(LT1-MS7W5T)
MOLDABLE COMFORT-TEK $79.00
SIZE
COMFORT-TEK™ (COMFORT-TEK)
STRETCH-AIR™ (STRETCH-AIR)
GLIDEWEAR® (GLIDEWEAR)
(LT1-MF4W3T)
(LT1-MF5W3T)
(LT1-MF5W4T)
(LT1-MF6W4T)
(LT1-MF6W6T)
(LT1-MF7W5T)
(LT1-MF4W3T)
(LT1-MF5W3T)
(LT1-MF5W4T)
(LT1-MF6W4T)
(LT1-MF6W6T)
(LT1-MF7W5T)
MOLDABLE ACTIVE STRETCH-AIR $79.00
SIZE
(LT1-MS4W3T-AL)
MOLDABLE ACTIVE COMFORT-TEK $79.00
SIZE
(LT1-MS5W3T-AL)
(LT1-MS5W4T-AL)
(LT1-MS6W4T-AL)
(LT1-MS6W6T-AL)
(LT1-MS7W5T-AL)
(LT1-MS4W3T-AR)
(LT1-MS5W3T-AR)
(LT1-MS5W4T-AR)
(LT1-MS6W4T-AR)
(LT1-MS6W6T-AR)
(LT1-MS7W5T-AR)
(LT1-MF4W3T-AL)
(LT1-MF5W3T-AL)
(LT1-MF5W4T-AL)
(LT1-MF6W4T-AL)
(LT1-MF6W6T-AL)
(LT1-MF7W5T-AL)
(LT1-MF4W3T-AR)
(LT1-MF5W3T-AR)
(LT1-MF5W4T-AR)
(LT1-MF6W4T-AR)
(LT1-MF6W6T-AR)
(LT1-MF7W5T-AR)
RIGID STRETCH-AIR $79.00
SIZE
(LT1-RS4W3T)
(LT1-RS5W3T)
(LT1-RS5W4T)
(LT1-RS6W4T)
(LT1-RS6W6T)
(LT1-RS7W5T)
(LT1-RS4W3T)
(LT1-RS5W3T)
(LT1-RS5W4T)
(LT1-RS6W4T)
(LT1-RS6W6T)
(LT1-RS7W5T)
RIGID COMFORT-TEK $79.00
SIZE
(LT1-RF4W3T)
(LT1-RF5W3T)
(LT1-RF5W4T)
(LT1-RF6W4T)
(LT1-RF6W6T)
(LT1-RF7W5T)
(LT1-RF4W3T)
(LT1-RF5W3T)
(LT1-RF5W4T)
(LT1-RF6W4T)
(LT1-RF6W6T)
(LT1-RF7W5T)
RIGID ACTIVE STRETCH-AIR $79.00
SIZE
(LT1-RS4W3T-AL)
RIGID ACTIVE COMFORT-TEK
$230.00/EA
SIZE
(LT1-RS5W3T-AL)
(LT1-RS5W4T-AL)
(LT1-RS6W4T-AL)
(LT1-RS6W6T-AL)
(LT1-RS7W5T-AL)
(LT1-RS4W3T-AR)
(LT1-RS5W3T-AR)
(LT1-RS5W4T-AR)
(LT1-RS6W4T-AR)
(LT1-RS6W6T-AR)
(LT1-RS7W5T-AR)
(LT1-RF4W3T-AL)
(LT1-RF5W3T-AL)
(LT1-RF5W4T-AL)
(LT1-RF6W4T-AL)
(LT1-RF6W6T-AL)
(LT1-RF7W5T-AL)
(LT1-RF4W3T-AR)
(LT1-RF5W3T-AR)
(LT1-RF5W4T-AR)
(LT1-RF6W4T-AR)
(LT1-RF6W6T-AR)
(LT1-RF7W5T-AR)
LEFT RIGHTEXTRA RIGHT
EXTRA LEFT LEFT RIGHT
EXTRA RIGHT
EXTRA LEFT
LEFT RIGHTEXTRA RIGHT
EXTRA LEFT LEFT RIGHT
EXTRA RIGHT
EXTRA LEFT
LEFT RIGHTEXTRA RIGHT
EXTRA LEFT LEFT RIGHT
EXTRA RIGHT
EXTRA LEFT
LEFT RIGHT EXTRA RIGHT
EXTRA LEFT
LEFT RIGHT EXTRA RIGHT
EXTRA LEFT
- OR - - OR -
- OR - - OR -
STR
ETC
H-A
IR™
CO
MFO
RT-
TEK
™HCPCS Code: E0956
HCPCS Code: E0955
HCPCS Code: E1028
HCPCS Code: E0956
HCPCS Code: E1028
3/3CD-ACTA-EMBRACE-SHORTFORM REV0217
SUBMIT BY EMAIL
*Length (L) refers to the actual size dimension of the support from bottom to top edge.
*Length (L) refers to the actual size dimension of the support from bottom to top edge.
Care for each fabric is identical.
4” D X 3” L5” D X 3” L5” D X 4” L6” D X 4” L6” D X 6” L7” D X 5” L
4” D X 3” L5” D X 3” L5” D X 4” L6” D X 4” L6” D X 6” L7” D X 5” L
4” D X 3” L5” D X 3” L5” D X 4” L6” D X 4” L6” D X 6” L7” D X 5” L
4” D X 3” L5” D X 3” L5” D X 4” L6” D X 4” L6” D X 6” L7” D X 5” L
4” D X 3” L5” D X 3” L5” D X 4” L6” D X 4” L6” D X 6” L7” D X 5” L
4” D X 3” L5” D X 3” L5” D X 4” L6” D X 4” L6” D X 6” L7” D X 5” L
4” D X 3” L5” D X 3” L5” D X 4” L6” D X 4” L6” D X 6” L7” D X 5” L
4” D X 3” L5” D X 3” L5” D X 4” L6” D X 4” L6” D X 6” L7” D X 5” L
