custom acta-back - short order form hcpcs code: e2617 · custom acta-back® - short order form...
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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
$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:
Patient Reference:
10-20” Width / 10-18” Length = $923 Base Price21-24” Width / 10-18” Length = $1014 Base Price10-24” Width / 19-22” Length = $1042 Base Price25-28” Width / 10-22” Length = $1497 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) SFC1” (CD-TOP-VIS-XXS-1.00)
$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 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
V04
18
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.
$35.00PRIVACY 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
11 BODILINK® LATERAL TRUNK SUPPORT PAD STYLE
BASIC STYLE PREMIUM STYLE
Aluminum Stay Pockets
Moldable Aluminum Stays
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.
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*Power Mount Bracket required for all power chairs listed below.
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
$515.00
$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
COMPASS® 4 MOUNTING HARDWARE
2/4CD-ACTA-BACK-SHORTFORM REV0418
ORANGE (CD-ORANGE)
A. SIZE & SHAPESHAPE SIZE LEFT RIGHT
SUP
PO
RTI
VE
L
D
3”L x 4”D BL-LTSP1S-3L4D-LH BL-LTSP1S-3L4D-RH3”L x 5”D BL-LTSP1S-3L5D-LH BL-LTSP1S-3L5D-RH4”L x 5”D BL-LTSP1S-4L5D-LH BL-LTSP1S-4L5D-RH4”L x 6”D BL-LTSP1S-4L6D-LH BL-LTSP1S-4L6D-RH5”L x 7”D BL-LTSP1S-5L7D-LH BL-LTSP1S-5L7D-RH6”L x 6”D BL-LTSP1S-6L6D-LH BL-LTSP1S-6L6D-RH
AC
TIV
E L
D
3”L x 4”D BL-LTSP1A-3L4D-LH BL-LTSP1A-3L4D-RH3”L x 5”D BL-LTSP1A-3L5D-LH BL-LTSP1A-3L5D-RH4”L x 5”D BL-LTSP1A-4L5D-LH BL-LTSP1A-4L5D-RH4”L x 6”D BL-LTSP1A-4L6D-LH BL-LTSP1A-4L6D-RH5”L x 7”D BL-LTSP1A-5L7D-LH BL-LTSP1A-5L7D-RH6”L x 6”D BL-LTSP1A-6L6D-LH BL-LTSP1A-6L6D-RH
B. STYLE STYLE LEFT RIGHT
MOLDABLE LTS-P1-MOLD LTS-P1-MOLD
RIGID LTS-P1-RIGID LTS-P1-RIGID
C. COVERCOVER LEFT RIGHT
COMFORT-TEK™ LTS-P1-COMFORT LTS-P1-COMFORTSTRETCH-AIR™ LTS-P1-STRETCH LTS-P1-STRETCH
A. SIZE & SHAPESHAPE SIZE LEFT RIGHT
SUP
PO
RTI
VE
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
AC
TIV
E 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 of either Basic or Premium Style Pads.Follow each column down to sections B and C and select a style and cover for each pad selected in section A. GT1 and GT2 Hardware and Pads are interchangeable.
HCPCS Code: E0956
- OR - - OR -
$82.00ea. $88.00ea.*EXTRA LEFT *EXTRA LEFT*EXTRA RIGHT *EXTRA RIGHT
*EXTRA LEFT *EXTRA LEFT*EXTRA RIGHT *EXTRA RIGHT
*EXTRA LEFT *EXTRA LEFT*EXTRA RIGHT *EXTRA RIGHT
*”EXTRA” parts may not fit depending on back support, pad, and hardware size and style combinations (especially back supports 16’L or less). Please contact customer support with questions. 1.800.564.9248
12 BODILINK® LTS HARDWARE 14 BODILINK® HEAD SUPPORT PAD
13 ADDITIONAL LTS HARDWARE
HCPCS Code: E0955
*Length (L) refers to the actual size dimension of the support from bottom to top edge.
$237.00/EA
3/4CD-ACTA-BACK-SHORTFORM REV0418
$129.00/EA
GT
GT
GT2
GT2
Slot Mount not available on 12”L or smaller Acta-Backs®.Track Mount only to be used with Compass® 4 Hardware (no 4PT on 10L - 14L backs.)*”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
$271.00ea.
LEFT BL-LTS-GT1SAS-LH
*EXTRA LEFT BL-LTS-GT1SAS-LH
RIGHT BL-LTS-GT1SAS-RH
*EXTRA RIGHT BL-LTS-GT1SAS-RH
FIXED
FIX
ED SLOT
MOUNT$129.00ea.
LEFT BL-LTS-GT1FXS-LH
*EXTRA LEFT BL-LTS-GT1FXS-LH
RIGHT BL-LTS-GT1FXS-RH
*EXTRA RIGHT BL-LTS-GT1FXS-RH
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
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
EXTRA HARDWARE LINKS1”
$37.00ea.
LEFT BL-LTS-GT1LINK
ADDITIONAL LEFT BL-LTS-GT1LINK
RIGHT BL-LTS-GT1LINK
ADDITIONAL RIGHT BL-LTS-GT1LINK
HARDWARE COVER
$26.00ea.
LEFT BL-LTS-HCOVER
EXTRA LEFT BL-LTS-HCOVER
RIGHT BL-LTS-HCOVER
EXTRA RIGHT BL-LTS-HCOVER
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
SWING-AWAY HCPCS Code: E1028
SWIN
G-A
WA
Y
Open Position
SLOT MOUNT
$298.00ea.
LEFT BL-LTS-GT2SAS-LH
*EXTRA LEFT BL-LTS-GT2SAS-LH
RIGHT BL-LTS-GT2SAS-RH
*EXTRA RIGHT BL-LTS-GT2SAS-RH
TRACK MOUNT
$298.00ea.
LEFT BL-LTS-GT2SAT-LH
*EXTRA LEFT BL-LTS-GT2SATX-LH
RIGHT BL-LTS-GT2SAT-RH
*EXTRA RIGHT BL-LTS-GT2SATX-RH
FIXED
FIX
ED
SLOT MOUNT
$178.00ea.
LEFT BL-LTS-GT2FXS-LH
*EXTRA LEFT BL-LTS-GT2FXS-LH
RIGHT BL-LTS-GT2FXS-RH
*EXTRA RIGHT BL-LTS-GT2FXS-RH
TRACK MOUNT
$178.00ea.
LEFT BL-LTS-GT2FXT-LH
*EXTRA LEFT BL-LTS-GT2FXTX-LH
RIGHT BL-LTS-GT2FXT-RH
*EXTRA RIGHT BL-LTS-GT2FXTX-RH
Additional LTS hardware will only work with their designated hardware style.
L
W
Make a selection in sections A -or- B.
B1. BASIC PAD COVER MATERIAL
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
B. BASIC PAD SIZE
6Wx5L BL-HSP3-6W3L
8W x 5L BL-HSP3-8W5L
10W x 6L BL-HSP3-10W6L
12W x 6L BL-HSP3-12W6L
14W x 6L BL-HSP3-14W6L
14W x 6L BL-HSP3-18W6L
L
W
4/4CD-ACTA-BACK-SHORTFORM REV0418
NOTES
15 BODILINK® HEAD SUPPORT HARDWAREHCPCS Code: E1028
16 HEAD SUPPORT MOUNTING OPTION
MOUNTING BLOCK-POSTERIOR A
17 EXTRA HARDWARE
1/4” SPACER PLATE2” LINK 3” LINK
Make a selection in sections A -or- B.
A. PT HARDWARE, REMOVABLEP
T H
AR
DW
AR
E, M
ID 6
PT
HA
RD
WA
RE
, L
AT
6
PT
HA
RD
WA
RE
, M
ID 8
PT
HA
RD
WA
RE
, L
AT
8
PT
HA
RD
WA
RE
, M
AX
8
SHAPE MSRPMID 6 $223.00 BL-HS-PT1RMMID6
LAT 6 $260.00 BL-HS-PT1RMLAT6
MID 8 $223.00 BL-HS-PT1RMMID8
LAT 8 $260.00 BL-HS-PT1RMLAT8
MAX 8 $327.00 BL-HS-PT1RMMAX8
B. GT HARDWARE, REMOVABLE
SHAPE MSRPLATERAL $228.00 BL-HS-GT3RMLAT
MID-LINE $191.00 BL-HS-GT3RMMID
GT
HA
RD
WA
RE
, L
AT
ER
AL
GT
HA
RD
WA
RE
, M
ID-L
INE
A1. PT HARDWARE, STEM LENGTH OPTION
LENGTH MSRPSTANDARD 7” STEM $0.00 HS-STEM-7
*3” STEM $0.00 HS-STEM-3
ST
AN
DA
RD
PT
ST
EM
, 7
”
PT
ST
EM
, 3
”
MSRPPOSTERIOR A
MOUNTING BLOCK $0.00 HS-MB-POSTA
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
1/4” SPACER PLATE $36.00 BL-HS-SPCRA
4” LINK TOOL-LESSWING LOCK
*FOR PT HARDWARE ONLY
* 3” Stem is recommended for use with power mounting where there may be special constraints with power chair functions
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