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ACTA-RELIEF CUSTOM SHORT ORDER FORM Client Reference: PAGE 1 of 4
*DO NOT SEND PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*
CUSTOM ACTA-RELIEF - SHORT ORDER FORM HCPCS CODE: E2617
1 BACK SUPPORT SIZE
C - R - 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” 14”W-16”W 1 BAG3” 18”W-20”W 1½ BAG4” 14”W 1 BAG4” 16”W-20”W 1½ BAG
3-4” Border
Gap for Foam in Place
Pleates
1” Viscool® Medium
½” Viscool® Soft
$309.00$412.00
$309.00$412.00
$309.00$412.00
$309.00$412.00
$309.00$412.00
$309.00$412.00
Company Name/ACCT #:
P.O. Number:
Requested By:
Phone: Fax:
Email:
Ship To:
Client Reference:
$0.00 $0.00 $0.00 $0.00
REAR LAYER *REQUIRED*
$0.00H.R. MEDIUM
1/4” (CD-REAR-HRM-0.25)
1/2” (CD-REAR-HRM-0.50) SFC3/4” (CD-REAR-HRM-0.75)
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® MEDIUM
1/2” (CD-REAR-VIS-M-0.50)
1” (CD-REAR-VIS-M-1.00)
VISCOOL® SOFT
1/2” (CD-REAR-VIS-S-0.50)
1” (CD-REAR-VIS-S-1.00)
VISCOOL® 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® MEDIUM
1/2” (CD-MID-VIS-M-0.50)
1” (CD-MID-VIS-M-1.00)
VISCOOL® SOFT
1/2” (CD-MID-VIS-S-0.50)
1” (CD-MID-VIS-S-1.00)
VISCOOL® 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® MEDIUM
1/2” (CD-TOP-VIS-M-0.50)
1” (CD-TOP-VIS-M-1.00)
VISCOOL® SOFT
1/2” (CD-TOP-VIS-S-0.50)
1” (CD-TOP-VIS-S-1.00)
VISCOOL® 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
$138.00
$138.00
$138.00
$138.00
$0.00
$0.00
$138.00
$138.00
$138.00
$138.00
$0.00
$0.00
$138.00
$138.00
$138.00
$138.00
NOTE: Desired back support length is “H” dimension in part number above. Cover and Boa® appearance may vary with hardware and size selection. Acta-Relief™ is limited to the sizes shown.
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.
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.
3 MILITARY BRANCH PATCH ARMY(CD-ARMY-PATCH)
AIR FORCE(CD-AIR-FORCE-PATCH)
NAVY(CD-NAVY-PATCH)
MARINES(CD-MARINES-PATCH)
*OPTIONAL*
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.
Leng
th
22”20”18”16”14”12”10”
14” 16” 18” 20”Width
$1,692.00
12”L back supports are not available with 4 PT hardware when using lateral trunk supports.
10”L Acta-Relief back supports are not available with 4 PT or Power Mount hardware, lateral trunk supports or a head support.
SFC = Standard Foam Configuration. Use as a reference when choosing foam layers. Keep in mind that thicker or firmer foams may decrease the level of patient immersion.
=1” (CD-TOP-VIS-XXS-1.00) SFC
*DO NOT SEND PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*
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.
*Since U.S. Medicare coding is subject to change, the provider should always confirm the HCPCS code and coverage criteria as part of the client assessment process.*
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ACTA-RELIEF CUSTOM SHORT ORDER FORM Client Reference: PAGE 2 of 4
*DO NOT SEND PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*
7 COLOR *OPTIONAL* $0.00
RED (CD-RED)
PURPLE (CD-PURPLE)
PINK (CD-PINK)
BLUE (CD-BLUE)
GREEN (CD-GREEN)
REMOVE (CD-REMOVE)
THREAD COLOR
Privacy Flap connects with hook and loop attachment between the seat and back support for added privacy.
PRIVACY 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
WORD(S)
Helvetica (CD-EMB-HELVETICA)
Garamond (CD-EMB-GARAMOND)
(CD-EMB-TWILIGHT)
(CD-EMB-SCRIPT)
WORD ONE
WORD TWO
A. B.
C.
8 PRIVACY FLAP *OPTIONAL* 9 EMBROIDERY *OPTIONAL* $0.00$35.00
6 HARDWARE OPTIONS
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.
Privacy Flap
COLOR LOCATION
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.
QUICK RELEASE COMPASS® 4 (2 PT)(CD-Q-COMPASS)
FIXED COMPASS® 4 (2 PT)(CD-NQ-COMPASS)
FIXED COMPASS® 4 (4 PT)(CD-NQ-COMPASS4)
QUICK RELEASE COMPASS® 4 (4 PT)(CD-Q-COMPASS4)
COMPASS® 4 BUNDLE(2 PT, 4 PT, QUICK RELEASE & FIXED)(CD-COMPASS-BUNDLE)
$0.00
$0.00
$0.00
$0.00
$481.00
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 10”L back supports *Power Mount Bracket required for all power chairs listed below.
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)
$515.00
$515.00
$515.00
$515.00
$515.00
**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
10 BODILINK LATERAL TRUNK SUPPORT PAD STYLE
PREMIUM STYLE
A. SIZE & SHAPESHAPE SIZE LEFT RIGHT
SUPP
ORT
IVE
L
D
3”L x 4”D BL-LTSP2S-3L4D-LH BL-LTSP2S-3L4D-RH
3”L x 5”D BL-LTSP2S-3L5D-LH BL-LTSP2S-3L5D-RH
4”L x 5”D BL-LTSP2S-4L5D-LH BL-LTSP2S-4L5D-RH
4”L x 6.5”D BL-LTSP2S-4L6D-LH BL-LTSP2S-4L6D-RH
5”L x 6.5”D BL-LTSP2S-5L6D-LH BL-LTSP2S-5L6D-RH
6”L x 6.5”D BL-LTSP2S-6L6D-LH BL-LTSP2S-6L6D-RH
ACT
IVE L
D
3”L x 4”D BL-LTSP2A-3L4D-LH BL-LTSP2A-3L4D-RH
3”L x 5”D BL-LTSP2A-3L5D-LH BL-LTSP2A-3L5D-RH
4”L x 5”D BL-LTSP2A-4L5D-LH BL-LTSP2A-4L5D-RH
4”L x 6.5”D BL-LTSP2A-4L6D-LH BL-LTSP2A-4L6D-RH
5”L x 6.5”D BL-LTSP2A-5L6D-LH BL-LTSP2A-5L6D-RH
6”L x 6.5”D BL-LTSP2A-6L6D-LH BL-LTSP2A-6L6D-RH
B. STYLE STYLE LEFT RIGHT
MOLDABLE LTS-P2-MOLD LTS-P2-MOLD
RIGID LTS-P2-RIGID LTS-P2-RIGID
C. COVERCOVER MSRP LEFT RIGHT
NO COVER $0 LTS-P2-NO-CV LTS-P2-NO-CVCOMFORT-TEK® $0 LTS-P2-COMFORT LTS-P2-COMFORTSTRETCH-AIR® $0 LTS-P2-STRETCH LTS-P2-STRETCHGLIDEWEAR® $13.00ea. LTS-P2-GLIDE LTS-P2-GLIDE
COMFORT-TEK® w/ FOAM $13.00ea. LTS-P2-COMFORT-FM LTS-P2-COMFORT-FMSTRETCH-AIR® w/ FOAM $13.00ea. LTS-P2-STRETCH-FM LTS-P2-STRETCH-FMGLIDEWEAR® w/ FOAM $26.00ea. LTS-P2-GLIDE-FM LTS-P2-GLIDE-FM
You may make one selection per column (Left, Extra Left, Right, and Extra Right) in section A. Follow each column down to sections B and C and select a style and cover for each pad selected in section A.
HCPCS Code: E0956
- OR -
$88.00ea.
*EXTRA LEFT *EXTRA RIGHT
*EXTRA LEFT *EXTRA RIGHT
*EXTRA RIGHT
ORANGE (CD-ORANGE)
11 BODILINK LTS HARDWARE
GT2
Not available on all sizes. See restrictions on page 1 by size chart.*”EXTRA” parts may not fit depending on back support, pad, and hardware size and style combinations (especially back supports 16’L or less).
SWING-AWAY HCPCS Code: E1028
SWIN
G-A
WA
Y
Open Position
SLOT MOUNT$298.00ea.
LEFT BL-LTS-GT2SAK-LH
*EXTRA LEFT BL-LTS-GT2SAK-LH
RIGHT BL-LTS-GT2SAK-RH
*EXTRA RIGHT BL-LTS-GT2SAK-RH
FIXED
FIXE
D SLOT MOUNT$178.00ea.
LEFT BL-LTS-GT2FXK-LH
*EXTRA LEFT BL-LTS-GT2FXK-LH
RIGHT BL-LTS-GT2FXK-RH
*EXTRA RIGHT BL-LTS-GT2FXK-RH
12 ADDITIONAL LTS HARDWAREGT2
EXTRA HARDWARE LINKS1¼”
$37.00ea.
LEFT BL-LTS-GT2LINK
ADDITIONAL LEFT BL-LTS-GT2LINK
RIGHT BL-LTS-GT2LINK
ADDITIONAL RIGHT BL-LTS-GT2LINK
LONG MOUNTING BRACKET
adds 1” of adjustment per bracket
$37.00ea.
LEFT BL-LTS-GT2LSLOT-LH
EXTRA LEFT BL-LTS-GT2LSLOT-LH
RIGHT BL-LTS-GT2LSLOT-RH
EXTRA RIGHT BL-LTS-GT2LSLOT-RH
HARDWARE COVER
$26.00ea.
LEFT BL-LTS-HCOVER
EXTRA LEFT BL-LTS-HCOVER
RIGHT BL-LTS-HCOVER
EXTRA RIGHT BL-LTS-HCOVER
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ACTA-RELIEF CUSTOM SHORT ORDER FORM Client Reference: PAGE 3 of 4
*DO NOT SEND PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*
13 BODILINK HEAD SUPPORT PADHCPCS Code: E0955*Length (L) refers to the actual size dimension of the support from bottom to top edge.
$237.00/EA
L
W
SHAPE MSRPMID 8 $223.00 BL-HS-PT1RMMID8
LAT 8 $260.00 BL-HS-PT1RMLAT8
MAX 8 $327.00 BL-HS-PT1RMMAX8
MID 6 $223.00 BL-HS-PT1RMMID6
LAT 6 $260.00 BL-HS-PT1RMLAT6
14 BODILINK HEAD SUPPORT HARDWAREHCPCS Code: E1028
A. PT HARDWARE, REMOVABLE
PT H
ARD
WAR
E, M
ID 6
PT H
ARD
WAR
E, L
AT 6
PT H
ARD
WAR
E, M
ID 8
PT H
ARD
WAR
E, L
AT 8
PT H
ARD
WAR
E, M
AX 8
A1. PT HARDWARE STEM LENGTH OPTION
LENGTH MSRPSTANDARD 7” STEM $0.00 HS-STEM-7
*3” STEM $0.00 HS-STEM-3
STAN
DAR
DPT
STE
M, 7
”
PT S
TEM
, 3”
15 BODILINK HEAD SUPPORT MOUNTING OPTION
MSRP*Acta-Relief™ 14W Bracket
with Mounting Block $72.00 HS-MB-AR14W
*Acta-Relief™ 16W Bracket with Mounting Block $72.00 HS-MB-AR16W
*Acta-Relief™ 18W Bracket with Mounting Block $72.00 HS-MB-AR18W
*Acta-Relief™ 20W Bracket with Mounting Block $72.00 HS-MB-AR20W
POSTERIOR A MOUNTING BLOCK $0.00 HS-MB-POSTA
BRACKET AND MOUNTING BLOCK-
ACTA-RELIEF™18W Shown Above
*For Non-Power Mount Only.*
MOUNTING BLOCK-POSTERIOR A
For *Acta-Relief with Power Mount Only*
* For Acta Relief™, includes mounting bracket and POSTA block. If you already have an Acta-Relief™ head support bracket, order POSTA Block
16 EXTRA HARDWARE
1/4” SPACER PLATE
2” LINK 3” LINK
MSRP**EXTRA 2” LINK $57.00 BL-HS-PT1LINK2
**EXTRA 3” LINK $57.00 BL-HS-PT1LINK3
**EXTRA 4” LINK $57.00 BL-HS-PT1LINK4
**TOOL-LESS WING LOCK $21.00/each BL-HS-52WINGA1 BL-HS-52WINGA1
BL-HS-52WINGA1 BL-HS-52WINGA1
4” LINK TOOL-LESSWING LOCK
MSRP*Acta-Relief™ 14W Bracket $152.00 BL-HS-AR14W
*Acta-Relief™ 16W Bracket $152.00 BL-HS-AR16W
*Acta-Relief™ 18W Bracket $152.00 BL-HS-AR18W
*Acta-Relief™ 20W Bracket $152.00 BL-HS-AR20W
1/4” SPACER PLATE $37.00 BL-HS-SPCRA
*Does not include a posterior mounting block. Mounting Bracket only. Purchase required when using a non-Comfort Company head support with COMPASS® 4 (2 Point or 4 Point) Hardware.
BRACKET-ACTA-RELIEF™
18W Shown Above
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
You may make one selection per section A or B.If choosing hardware in section A, choose a stem length option in section A1.
B. PT HARDWARE, FLIP-DOWN
PT H
ARD
WAR
E, M
ID 6
PT H
ARD
WAR
E, L
AT 6
PT H
ARD
WAR
E, M
ID 8
PT H
ARD
WAR
E, L
AT 8
PT H
ARD
WAR
E, M
AX 8
SHAPE MSRPMID 6 $273.00 BL-HS-PT1FDMID6
LAT 6 $310.00 BL-HS-PT1FDLAT6
MID 8 $273.00 BL-HS-PT1FDMID8
LAT 8 $310.00 BL-HS-PT1FDLAT8
MAX 8 $357.00 BL-HS-PT1FDMAX8
*3” Stem is recommended for use with power mounting where there may be special constraints with power chair functions
A1. PREMIUM PAD COVER MATERIAL
GlideWear® provides skin protection and shear reduction. Not fluid resistant. GLIDEWEAR® GLIDEWEAR (ADD $26.00)
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
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ACTA-RELIEF CUSTOM SHORT ORDER FORM Client Reference: PAGE 4 of 4
*DO NOT SEND PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*
NOTES
SUBMIT BY EMAILThe following are trademarks and registered trademarks of Permobil Seating and Positioning: BodiLink®, Comfort-Tek®, Compass®, and Stretch-Air®.Glidewear® is a registered trademark of Tamarack Habilitation Technologies, Inc. Viscool® is a registered trademark of American Excelsior Company, Inc.