CUSTOM ACTA-BACK® DEEP - SHORT ORDER FORMHCPCS CODE: E2617

1 BACK SUPPORT SIZE

C - D - W HHCPCS Code: E2617

2 COVER OPTIONS

4 CUSTOM FOAM SELECTION

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)

Rear LayerMiddle Layer

Topper Layer

A minimum of one layer must be chosen. A ¼” Crosslink foundation layer comes standard on all back supports.

$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

12-20” Width / 12-18” Length = $1069.00 Base Price21-24” Width / 12-18” Length = $1175.00 Base Price12-24” Width / 19-22” Length = $1206.00 Base Price25-28” Width / 12-22” Length = $1734.00 Base Price

*If desired size is not listed above, a 60% up charge will be applied for materials.

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

3 MILITARY BRANCH PATCH

AIR FORCE $0.00(CD-AIR-FORCE-PATCH)

ARMY $0.00(CD-ARMY-PATCH)

MARINES $0.00(CD-MARINES-PATCH)

NAVY $0.00(CD-NAVY-PATCH)

(OPTIONAL)

Company Name/ACCT #:

P.O. Number:

Requested By:

Phone: Fax:

Email:

Ship To:

Patient Reference:

5 MOLDABLE ALUMINUM STAYSSPACE BETWEEN STAYS $0.00

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.

1” (CD-STAY-1.0)

1 1/2” (CD-STAY-1.5)

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)

Aluminum Stay Pockets

Moldable Aluminum Stays

Choose either Stretch-Air or Comfort-Tek cover fabric with Diamond or Digi-Camo accent fabric. Care for each accent fabric is identical.

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NOTE: Desired back support length is “H” dimension in part number above. Cover appearance may vary with hardware selection and size.

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 customs@comfortcompany.com or print and fax to 1.406.522.8563.

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.

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

7 COLOR (OPTIONAL)COLOR

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.

$0.00

RED (CD-RED)

PURPLE (CD-PURPLE)

PINK (CD-PINK)

BLUE (CD-BLUE)

GREEN (CD-GREEN)

ORANGE (CD-ORANGE)

Privacy Flap connects with hook and loop attachment between the seat and back support for added privacy.

$35.00PRIVACY FLAP (CD-PF-CV)

8 PRIVACY FLAP (OPTIONAL)

COLOR LOCATION

$0.00THREAD COLOR OPTIONS

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 EMBROIDERY (OPTIONAL)

$0.00

10 SINGLE LATERAL DEPTH$0.00LATERAL DEPTH

OMIT LEFT (CD-DEEP-LAT-L-OMIT)

OMIT RIGHT (CD-DEEP-LAT-R-OMIT)

3” D x 5” L LEFT (CD-DEEP-LAT-L-3)

3” D x 5” L RIGHT (CD-DEEP-LAT-R-3)

5” D x 6” L LEFT (CD-DEEP-LAT-L-5)

5” D x 6” L RIGHT (CD-DEEP-LAT-R-5)

7” D x 7” L LEFT (CD-DEEP-LAT-L-7)

7” D x 7” L RIGHT (CD-DEEP-LAT-R-7)

Laterals are mounted at a fixed height position. Laterals are width and angle adjustable. Lateral pad height changes with different depth selections. If specific wing height location is needed, please indicate in the notes below.

7” 7”5” 5” 7”

22”

9” 11” 12” 13” 13”

7”

14”

18” L Back Support

EXAMPLE

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*Length (L) refers to the actual size dimension of the support from bottom to top edge.

6 HARDWARE OPTIONS

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 back supports smaller than 12”L or 12” W, or sizes 12Wx16L & 12Wx18L*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

REMOVE (CD-REMOVE)

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

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

L

W

$129.00/EA$237.00/EA

11 BODILINK® HEAD SUPPORT PAD STYLEHCPCS Code: E0955

*Length (L) refers to the actual size dimension of the support from bottom to top edge.

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

NOTES

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12 BODILINK® HEAD SUPPORT HARDWAREHCPCS Code: E1028

13 BODILINK® HEAD SUPPORT MOUNTING OPTION

MOUNTING BLOCK-POSTERIOR A

14 ADDITIONAL WINGS AND LINKS

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 $37.00 BL-HS-SPCRA

4” LINK TOOL-LESSWING LOCK

SUBMIT BY EMAIL

*3” Stem is recommended for use with power mounting where there may be special constraints with power chair functions

**For PT Hardware Only