custom acta-back - short order form hcpcs code:...

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CUSTOM ACTA-BACK® - SHORT ORDER FORM HCPCS CODE: E2617

1 BACK SUPPORT SIZE

C - A - 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)


1/2” (CD-MID-VIS-XS-0.50)

1” (CD-MID-VIS-XS-1.00)


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)


1/2” (CD-TOP-VIS-XS-0.50)

1” (CD-TOP-VIS-XS-1.00)


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 appearance may vary with hardware selection and size.

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-B

AC

K-S

HO

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.

SFC = Standard Foam Configuration. Use as a reference when choosing foam layers. =1” (CD-TOP-VIS-XXS-1.00) SFC

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)

SPECIFY CUSTOM SPACING(CD-STAY-OTHER)

NONE (CD-STAY-NONE)

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.

8 COLOR (OPTIONAL)COLOR $0.00

RED (CD-RED)

PURPLE (CD-PURPLE)

PINK (CD-PINK)

BLUE (CD-BLUE)

GREEN (CD-GREEN)

REMOVE (CD-REMOVE)

$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.

9 PRIVACY FLAP (OPTIONAL) 10 EMBROIDERY (OPTIONAL)

$0.00

7 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

12 LATERAL TS HARDWARESWING 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”

13 HARDWARE COVER (OPTIONAL)

PROTECTIVE LATERAL HARDWARE COVER

$19.00/EA

LEFT (LT1-PROTECT2)

1 ADD’L LEFT

1 ADD’L RIGHT

RIGHT(LT1-PROTECT2)

3”

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11 LATERAL TRUNK SUPPORT PAD STYLEMOLDABLE 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



EXTRA RIGHT

EXTRA LEFT



EXTRA RIGHT

EXTRA LEFT

LEFT RIGHT EXTRA RIGHT

EXTRA LEFT

LEFT RIGHT EXTRA RIGHT

EXTRA LEFT

- OR - - OR -

- OR - - OR -

Aluminum Stay Pockets

Moldable Aluminum Stays

STR

ETC

H-A

IR™

CO

MFO

RT-

TEK

™

COLOR LOCATION

CD-ACTA-BACK-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® 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, or sizes 12Wx16L & 12Wx18L

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)

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)

$0.00

$0.00

$0.00

$0.00

$466.67

$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

COMPASS® 4 MOUNTING HARDWARE

NOTES

3/3CD-ACTA-BACK-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/EA

$35.00/EA

14 BODILINK HEAD SUPPORT PAD STYLE

15 BODILINK HEAD SUPPORT PAD COVER

16 HEAD SUPPORT HARDWARE

REMOVABLE HARDWARE

½” SHAFT (BL-HSH-FX)

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





L

PAD FIRMNESS

$230.00/EA

Bodi-Link Head Support Patent Pending

W

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