CUSTOM ACTA-BACK ORDER FORM Client Reference: PAGE 1 of 3
*DO NOT SEND PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*
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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 BAG3” 17”W-22”W 1½ BAG4” 10”W-14”W 1 BAG4” 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:
Client 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*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)
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) 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 *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. *DO NOT SEND PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*
*Please note that 10L sizes are not available with lateral trunk supports or a head support.
®*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.*
AIR FORCE $0.00 ARMY $0.00 MARINES $0.00 NAVY $0.00(CD-AIR-FORCE-PATCH) (CD-ARMY-PATCH) (CD-MARINES-PATCH) (CD-NAVY-PATCH)
SFC = Standard Foam Configuration. Use as a reference when choosing foam layers. =1” (CD-TOP-VIS-XXS-1.00) SFC
CUSTOM ACTA-BACK ORDER FORM Client Reference: PAGE 2 of 3
*DO NOT SEND PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*
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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
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
ORANGE (CD-ORANGE)
12 BODILINK LTS HARDWARE
(Input is case sensitive. Please enter exactly as you want the words to look. Example: Marcus or marcus or MARCUS)
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-CV
COMFORT-TEK® $0 LTS-P2-COMFORT LTS-P2-COMFORT
STRETCH-AIR® $0 LTS-P2-STRETCH LTS-P2-STRETCH
GLIDEWEAR® $13.00ea. LTS-P2-GLIDE LTS-P2-GLIDE
COMFORT-TEK® w/ FOAM $13.00ea. LTS-P2-COMFORT-FM LTS-P2-COMFORT-FM
STRETCH-AIR® w/ FOAM $13.00ea. LTS-P2-STRETCH-FM LTS-P2-STRETCH-FM
GLIDEWEAR® 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 LEFT *EXTRA RIGHT
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
$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
FIXE
D
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
CUSTOM ACTA-BACK ORDER FORM Client Reference: PAGE 3 of 3
*DO NOT SEND PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*
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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
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
NOTES
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 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
Additional LTS hardware will only work with their designated hardware style.
L
W
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
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
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”
* 3” Stem is recommended for use with power mounting where there may be special constraints with power chair functions
MSRPPOSTERIOR A
MOUNTING BLOCK $0.00 HS-MB-POSTA
MSRPEXTRA 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
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
You may make one selection per section A or B.If choosing hardware in section A, choose a stem length option in section A1.
SUBMIT BY EMAILThe following are trademarks and registered trademarks of Permobil Seating and Positioning: ACTA-BACK®, 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.