1/3 CUSTOM ACTA-RELIEF™ - SHORT ORDER FORM HCPCS CODE: E2617 1 BACK SUPPORT SIZE C - R - 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” 14”W-16”W 1 BAG 3” 18”W-20”W 1½ BAG 4” 14”W 1 BAG 4” 16”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 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: $0.00 $0.00 $0.00 $0.00 REAR LAYER (REQUIRED) $0.00 H.R. MEDIUM 1/4” (CD-REAR-HRM-0.25) 1/2” (CD-REAR-HRM-0.50) SFC 3/4” (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 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 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) CD-ACTA-RELIEF-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. Patent Pending Length 22” 20” 18” 16” 14” 12” 10” 14” 16” 18” 20” Width $1,642.00 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
Transcript
1/3
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 BAG
3” 18”W-20”W 1½ BAG
4” 14”W 1 BAG
4” 16”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.)
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)
CD
-AC
TA-R
ELI
EF-
SHO
RTF
OR
M
RE
V02
17
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.
Patent Pending
Leng
th
22”20”18”16”14”12”10”
14” 16” 18” 20”Width
$1,642.00
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
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.
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
11 LATERAL TS HARDWARE
SWING AWAY E1028(WIDTH ADJUSTABLE)
$263.00
LEFT (LTL-SF-K)
1 ADD’L LEFT
A.
RIGHT (LTR-SF-K)
1 ADD’L RIGHT
ADDITIONAL LINKS (OPTIONAL)
$35.00
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
LEFT (LTL-RF-K)
1 ADD’L LEFT
RIGHT (LTR-RF-K)
1 ADD’L RIGHT
1”
12 HARDWARE COVER (OPTIONAL)
PROTECTIVE LATERAL HARDWARE COVER
$19.00
LEFT (LT1-PROTECT2)
1 ADD’L LEFT
1 ADD’L RIGHT
RIGHT(LT1-PROTECT2)
3”
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10 LATERAL TRUNK SUPPORT PAD STYLE HCPCS Code: E0956
MOLDABLE STRETCH-AIR $79.00
SIZE
4” D X 3” L
4” D X 3” L
4” D X 3” L
4” D X 3” L
4” D X 3” L
4” D X 3” L
4” D X 3” L
4” D X 3” L
5” D X 3” L
5” D X 3” L
5” D X 3” L
5” D X 3” L
5” D X 3” L
5” D X 3” L
5” D X 3” L
5” D X 3” L
5” D X 4” L
5” D X 4” L
5” D X 4” L
5” D X 4” L
5” D X 4” L
5” D X 4” L
5” D X 4” L
5” D X 4” L
6” D X 4” L
6” D X 4” L
6” D X 4” L
6” D X 4” L
6” D X 4” L
6” D X 4” L
6” D X 4” L
6” D X 4” L
6” D X 6” L
6” D X 6” L
6” D X 6” L
6” D X 6” L
6” D X 6” L
6” D X 6” L
6” D X 6” L
6” D X 6” L
7” D X 5” L
7” D X 5” L
7” D X 5” L
7” D X 5” L
7” D X 5” L
7” D X 5” L
7” D X 5” L
7” D X 5” L
(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
(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 $79.00
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
™
COLOR LOCATION
CD-ACTA-RELIEF-SHORTFORM REV0217
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 10”L back supports
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
NOTES
3/3CD-ACTA-RELIEF-SHORTFORM REV0217
SUBMIT BY EMAIL
provides skin protection and shear reduction. Not fluid resistant.
for fluid protection and an easily cleaned surface.
provides air transmission and heat dissipation.
$221.00
$286.07
$146.77
$35.00
13 BODILINK HEAD SUPPORT PAD STYLE
14 BODILINK HEAD SUPPORT PAD COVER
15 HEAD SUPPORT HARDWARE & BRACKET
REMOVABLE HARDWARE*
MOUNTING BRACKET & HARDWARE
MOUNTING BRACKET ONLY
HEAD SUPPORT HARDWARE ONLY
½” SHAFT (BL-HSH-FX)
14W BRACKET & HARDWARE (BL-HSH-FX-AR14W)
14W BRACKET (HSH-AR14W)
16W BRACKET & HARDWARE (BL-HSH-FX-AR16W)
16W BRACKET (HSH-AR16W)
18W BRACKET & HARDWARE (BL-HSH-FX-AR18W)
18W BRACKET (HSHAR18W)
20W BRACKET & HARDWARE (BL-HSH-FX-AR20W)
20W BRACKET (HSH-AR20W)
¼” SPACER (BL-HSH-SPCR)
¼”
EXTRA SPACER PLATE
EXTRA SPACER PLATE
COMFORT-TEK™ (COMFORT-TEK)
STRETCH-AIR™ (STRETCH-AIR)
GLIDEWEAR® (GLIDEWEAR)
HCPCS Code: E0955
HCPCS Code: E1028
*Length (L) refers to the actual size dimension of the support from bottom to top edge.
Care for each fabric is identical.
6W x 3½LExtra SoftSoft BL-HSP1-6W3L
BL-HSP2-6W3L
8W x 4L Extra SoftSoft BL-HSP1-8W4L
BL-HSP2-8W4L
Adjustable Wing 10W x 5L Extra Soft
Soft BL-HSP1-10W5LBL-HSP2-10W5L
Adjustable Wing 14W x 5L Extra Soft
Soft BL-HSP1-14W5LBL-HSP2-14W5L
Adjustable Wing 18W x 5L Extra Soft
Soft BL-HSP1-18W5LBL-HSP2-18W5L
L
PAD FIRMNESS
$230.00
Bodi-Link Head Support Patent Pending
W
Purchase required when using a non-Comfort Company head support with COMPASS® 4 (2 or 4 POINT) Hardware.
*Only available for Acta-Relief™ when using COMPASS® Power Mount Hardware.
BodiLink Head Support not available for 10”L Acta-Relief™ Back Supports
Required when using COMPASS® 4 hardware (2 or 4 POINT)
