ACTA-RELIEF BACK - FULL ORDER FORMd37xlajmpyyml6.cloudfront.net/...Acta-Relief.pdf · Acta-Relief...

ACTA-RELIEF™ BACK - FULL ORDER FORMHCPCS CODE: E2617

509 S. 22ND AVENUE | BOZEMAN, MT | PH. 800.564.9248 | FAX. 406.522.8563 | COMFORTCOMPANY.COM

Date:

Company Name/ACCT #:

Patient Name:

Patient Weight:

Patient Height:

Patient Reference:

Additional Information:

P.O. Number:

Requested By:

Phone: Fax:

Email:

Ship To:

Seat Frame Width:

Seat Frame Depth:

Seat Rail Tube Size:

A - Back Support Width

B - Back Support Length

C - Width Between Lateral Trunk Supports

D - Width Between Lateral Thigh Support

E - Seat Width

F - Seat Depth

G - Effective Seat Depth

H - Lateral Trunk Support Height

1/7

CUSTOMER/PATIENT INFORMATION

SEATING SYSTEM MEASUREMENTS

NOTE:Seating system measurements do not affect any selections made through the order form.

W/C Manufacturer:

Model #: Serial #:

Order #:

E

A

C

D

F

G

B

H

Patent Pending

CD

-AC

TA-R

ELI

EF-

BA

CK

-FO

RM

RE

V03

16

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.

1.1 BACK SUPPORT SIZE Select the desired back support size by clicking the correct size below or fill in the specific width and length measurements in the “Custom Back Part Number” box. ACTA-RELIEF IS LIMITED TO ONLY THE SIZES LISTED.

INSTRUCTIONS:

BACK SUPPORT SIZE & COVER MATERIAL1

C - R - W H

2/7

HCPCS CODE: E2617

Custom Back Support Part Number:

SIZES

LEN

GTH

*

FRAME WIDTH

C-R-14W22H C-R-16W22H C-R-18W22H C-R-20W22H







18”

12”

10”

20”

14”

22”

16”

16”14” 18” 20”

$1,642.00

$1,6

42.0

0

Order #: CD-ACTA-RELIEF-BACK-FORM REV0316

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

NOTE: Desired back support length is “H” dimension in part number above. Acta-Relief is limited to only the sizes listed in chart above.

NOTE:

12”L Acta-Relief 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.

Appearance and Boa® closure system may vary with size and hardware selection.

1.2 COVER MATERIAL OPTIONS* REQUIRED * MSRP $0.00

COVER FABRIC ACCENT FABRIC

STRETCH-AIR

DIAMOND(CD-STRETCH-AIR)

DIGI-CAMO (CD-DIGI-STRETCH-AIR)

COMFORT-TEK

DIAMOND(CD-COMFORT-TEK)

DIGI-CAMO (CD-DIGI-COMFORT-TEK)

Cover appearance may vary with hardware selection.

COMFORT-TEKTM

Comfort-Tek is a smooth, easily

cleaned surface. The fluid protection

aids in infection control.

STRETCH-AIRTM

Stretch-Air has comfortable

stretch, air transmission and heat

dissipation. It is not fluid resistant.

- OR -

- WIT

H -

DIAMOND OR DIGI-CAMO

ACCENT FABRIC

Choose either DIAMOND or DIGI-CAMO accent fabric. Care

for each fabric is identical.

MILITARY BRANCHPATCH (OPTIONAL)MSRP $0.00

1.3

Air Force (CD-AIR-FORCE-PATCH)

Army (CD-ARMY-PATCH)

Marines (CD-MARINES-PATCH)

Navy (CD-NAVY-PATCH)

Patch Placement

2.1 CUSTOM FOAM SELECTION

3/7

INSTRUCTIONS:

Select only one type of foam per layer.

Indicates standard Acta-Relief foam configuration. When choosing foam layers, please keep in mind that thicker and firmer foams may decrease the level of patient immersion.

A minimum of one layer must be chosen if Foam in Place is not selected in Section 2.2.

FOAM OPTIONS2

Order #: CD-ACTA-RELIEF-BACK-FORM REV0316

FOAM TYPE

H.R. Medium

H.R. Soft

ViscoolTM Medium

ViscoolTM Soft

ViscoolTM X-Soft

Visco XX-Soft

REAR LAYER (REQUIRED)

H.R. MSRP $0.00Viscool & Visco MSRP $133.33

MIDDLE LAYER(OPTIONAL)


TOPPER LAYER(OPTIONAL)


¼” ½” ¾” 1” 1¼” ¼” ½” ¾” 1” 1¼” ¼” ½” ¾” 1” 1¼”

(CD-Rear-HRM-0.25)

(CD-Rear-HRM-0.50)

(CD-Rear-HRM-0.75)

(CD-Rear-HRM-1.00)

(CD-Rear-HRM-1.25)

(CD-Mid-HRM-0.25)

(CD-Mid-HRM-0.50)

(CD-Mid-HRM-0.75)

(CD-Mid-HRM-1.00)

(CD-Mid-HRM-1.25)

(CD-Top-HRM-0.25)

(CD-Top-HRM-0.50)

(CD-Top-HRM-0.75)

(CD-Top-HRM-1.00)

(CD-Top-HRM-1.25)

(CD-Rear-HRS-0.25)

(CD-Rear-HRS-0.50)

(CD-Rear-HRS-0.75)

(CD-Rear-HRS-1.00)

(CD-Rear-HRS-1.25)

(CD-Mid-HRS-0.25)

(CD-Mid-HRS-0.50)

(CD-Mid-HRS-0.75)

(CD-Mid-HRS-1.00)

(CD-Mid-HRS-1.25)

(CD-Top-HRS-0.25)

(CD-Top-HRS-0.50)

(CD-Top-HRS-0.75)

(CD-Top-HRS-1.00)

(CD-Top-HRS-1.25)

(CD-Rear-VIS-M-0.50)

(CD-Rear-VIS-M-1.00)

(CD-Mid-VIS-M-0.50)

(CD-Mid-VIS-M-1.00)

(CD-Top-VIS-M-0.50)

(CD-Top-VIS-M-1.00)

(CD-Rear-VIS-S-0.50)

(CD-Rear-VIS-S-1.00)

(CD-Mid-VIS-S-0.50)

(CD-Mid-VIS-S-1.00)

(CD-Top-VIS-S-0.50)

(CD-Top-VIS-S-1.00)

(CD-Rear-VIS-XS-0.50)

(CD-Rear-VIS-XS-1.00)

(CD-Mid-VIS-XS-0.50)

(CD-Mid-VIS-XS-1.00)

(CD-Top-VIS-XS-0.50)

(CD-Top-VIS-XS-1.00)

(CD-Rear-VIS-XXS-0.50)

(CD-Rear-VIS-XXS-1.00)

(CD-Mid-VIS-XXS-0.50)

(CD-Mid-VIS-XXS-1.00)

(CD-Top-VIS-

XXS-0.50)

(CD-Top-VIS-

XXS-1.00)

REARLAYER

MIDDLELAYER

TOPPER LAYER¼” Crosslink

foundation layer comes standard on all back supports.

For other foam combinations call Customer Service 1.800.564.9248.

EXTRA SOFTMEMORY FOAM

1 Bag FIP Kit MSRP: $566.671 ½ Bag FIP Kit MSRP: $666.67

SOFT MEMORY FOAM


MEDIUMMEMORY FOAM


3” BACKBORDER

POUR SIZE

4” BACKBORDER

3” BACK BORDER

POUR SIZE

4” BACK BORDER

3” BACK BORDER

POUR SIZE

4” BACKBORDER

(CD-FIP3-1-XS) 1 BAG (CD-FIP4-1-XS) (CD-FIP3-1-S) 1 BAG (CD-FIP4-1-S) (CD-FIP3-1-M) 1 BAG (CD-FIP4-1-M)

(CD-FIP3-1.5-XS) 1 ½ BAG (CD-FIP4-1.5-XS) (CD-FIP3-1.5-S) 1 ½ BAG (CD-FIP4-1.5-S) (CD-FIP3-1.5-M) 1 ½ BAG (CD-FIP4-1.5-M)

FOAM IN PLACE KIT

KIT INCLUDES:

Two plastic bags are included to contain the foam chemicals as they expand.

INSTRUCTIONS:

1” of ViscoolTM Medium foam is cut to fit the shape of the back support, and is placed loosely inside the cover. This will give the user some pad-ding, prior to pouring the foam.

½” of ViscoolTM Soft foam is cut to fit the shape of the back support and is placed inside the front of the cover. This will give the final mold a plush feel for the user and will also smooth out any potential inconsistencies after pouring the foam.

- OR -

NOTE:

Select extra soft, soft or medium density memory foam bag pour.Select the appropriate pour size based on your choice of a 3” or 4” deep back support border.Contact Customer Service with any questions 1.800.564.9248.

Two aluminum stays sewn into the rear of the cover which can be molded to support spinal curvature prior to pouring FIP Chemicals.

3-4” Border

Gap for Foam in Place

Pleates

Back cushion cover with an optional 3” or 4” deep back, with a stretchy, pleated contact surface to allow for foam growth.

1” Viscool Medium

½” Viscool Soft

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

NOTE:

2.2

MSR

P $

0.00

MSR

P $

133.

33

4/7Order #: CD-ACTA-RELIEF-BACK-FORM REV0316

Red (CD-RED) Blue (CD-BLUE)

Purple (CD-PURPLE) Green (CD-GREEN)

Pink (CD-PINK) Remove (CD-REMOVE)

Fill out Sections A, B, & C.

WORD ONE

THREAD COLOR OPTIONS

Red (CD-EMB-RED) Blue (CD-EMB-BLUE)

Purple (CD-EMB-PURPLE) Green (CD-EMB-GREEN)

Pink (CD-EMB-PINK) Silver (CD-EMB-SILVER)

WORD TWO

- AND/OR -

A.

B.

C.

INSTRUCTIONS:

FONT/STYLE OPTIONS

Helvetica (CD-EMB-Helvetica) (CD-EMB-Twilight)

Garamond (CD-EMB-Garamond) (CD-EMB-Script)

3.2 COLOR (OPTIONAL) 3.3 EMBROIDERY (OPTIONAL) 3.4 PRIVACY FLAP (OPTIONAL)MSRP $0.00 MSRP $0.00 MSRP $33.33

Privacy Flap (CD-PF-CV)

NOTE:This flap connects with hook/loop attachment between the seat and back for added privacy.

Privacy Flap

Color Location

Placement of the piping may vary by back support size and mounting hardware.

NOTE:Accent colors can be applied via colored piping that is stitched to the flaps of the back support. If no colors are selected, our standard silver reflective piping will be used.

BACK SUPPORT OPTIONS3

COMPASS® POWER MOUNT BRACKET

MSRP $500.00

3.1 HARDWARE OPTIONS NOTE: Quick Release and Fixed hardware are adjustable for height, depth, width and angle of recline. Fixed requires tools for removal. 4-Point is designed to provide extra support for users with tone and for back supports 24” wide or greater. Compass® 4 hardware may be installed on 3/4”, 7/8”, 1”and 1 1/8” tubing. Power Mount Bracket is height adjustable up to 8” in 1/2” increments but may be limited by the chair.

COMPASS® 4 FIXED

(2 POINTS OF ATTACHMENT)MSRP $0.00

Fixed (2 point)(CD-NQ-COMPASS)

COMPASS® 4 FIXED


Fixed (4 point)(CD-NQ-COMPASS4)

COMPASS® 4 BUNDLE (2 PT, 4 PT,

FIXED & QUICK RELEASE) MSRP $466.67

Fixed (4 point)(CD-NQ-COMPASS4)

Quantum w/ Tru Balance 3(CD-PMB-QUANTUM)

Permobil w/ Corpus 3G(CD-PMB-PERMOBIL)

Quickie w/ 3.7 Power(CD-PMB-QUICKIE)

Rovi w/ Motion Concepts*(CD-PMB-ROVI)

COMPASS® 4 QUICK RELEASE


Quick Release (2 point)(CD-Q-COMPASS)

COMPASS® 4 QUICK RELEASE


Quick Release (4 point)(CD-Q-COMPASS4)

Quick Release Lever for Removal

Bolts Together

4 POINT

TOP VIEW

4 POINT

TOP VIEW

4 POINT

TOP VIEW

Not available on 10”L back supports.

Head Support Bracket not required for Acta-Relief when using Compass

Power Mount hardware.

4 Point hardware may not fit all smaller back support lengths.

*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.


LATERAL TRUNK SUPPORT & HARDWARE4 Optional

4.1 LATERAL TRUNK SUPPORT PAD STYLE Select a left and/or right lateral trunk support pad using any combination of size, style and fabric. STRETCH-AIR™

COMFORT-TEK™

has comfortable stretch,

air transmission and heat

dissipation.

is a smooth, easily cleaned

surface. The fluid protection

aids in infection control.

Contact Customer Service for custom sizes that are not listed below. 1.800.564.9248.

HCPCS Code: E0956 MSRP $79.00/ea.

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

L

D

L

D

L

D

L

D

MOLDABLE

RIGID

MOLDABLE ACTIVE

RIGID ACTIVE

4”D x 3”L 5”D x 3”L 5”D x 4”L 6”D x 4”L 6”D x 6”L 7”D x 5”L

COMFORT-TEK LT1-MF4W3T LT1-MF5W3T LT1-MF5W4T LT1-MF6W4T LT1-MF6W6T LT1-MF7W5T

Left Right Left Right Left Right Left Right Left Right Left Right

Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right Extra Left Extra Right

STRETCH-AIR LT1-MS4W3T LT1-MS5W3T LT1-MS5W4T LT1-MS6W4T LT1-MS6W6T LT1-MS7W5T



COMFORT-TEK LT1-MF4W3T-AL LT1-MF4W3T-AR LT1-MF5W3T-AL LT1-MF5W3T-AR LT1-MF5W4T-AL LT1-MF5W4T-AR LT1-MF6W4T-AL LT1-MF6W4T-AR LT1-MF6W6T-AL LT1-MF6W6T-AR LT1-MF7W5T-AL LT1-MF7W5T-AR



STRETCH-AIR LT1-MS4W3T-AL LT1-MS4W3T-AR LT1-MS5W3T-AL LT1-MS5W3T-AR LT1-MS5W4T-AL LT1-MS5W4T-AR LT1-MS6W4T-AL LT1-MS6W4T-AR LT1-MS6W6T-AL LT1-MS6W6T-AR LT1-MS7W5T-AL LT1-MS7W5T-AR



COMFORT-TEK LT1-RF4W3T LT1-RF5W3T LT1-RF5W4T LT1-RF6W4T LT1-RF6W6T LT1-RF7W5T



STRETCH-AIR LT1-RS4W3T LT1-RS5W3T LT1-RS5W4T LT1-RS6W4T LT1-RS6W6T LT1-RS7W5T



COMFORT-TEK LT1-RF4W3T-AL LT1-RF4W3T-AR LT1-RF5W3T-AL LT1-RF5W3T-AR LT1-RF5W4T-AL LT1-RF5W4T-AR LT1-RF6W4T-AL LT1-RF6W4T-AR LT1-RF6W6T-AL LT1-RF6W6T-AR LT1-RF7W5T-AL LT1-RF7W5T-AR



STRETCH-AIR LT1-RS4W3T-AL LT1-RS4W3T-AR LT1-RS5W3T-AL LT1-RS5W3T-AR LT1-RS5W4T-AL LT1-RS5W4T-AR LT1-RS6W4T-AL LT1-RS6W4T-AR LT1-RS6W6T-AL LT1-RS6W6T-AR LT1-RS7W5T-AL LT1-RS7W5T-AR



EXTRA LINKSMSRP $35.00/link

PROTECTIVE COVER (OPTIONAL)4.2

A) B)

4.3

RIGIDHCPCS Code: E0956

MSRP $125.00/bracket

SWING-AWAYHCPCS Code: E1028

MSRP $263.00/ea

PROTECTIVE LATERAL HARDWARE COVER

MSRP $19.00/ea

Select a set of hardware below (Section A). Extra links (Section B) may be selected to add 1” of additional depth and adjustability.

CLOSED OPEN

3” 3”1”

EXTRA LINK

LATERAL TRUNK SUPPORT HARDWARE

LTL-SF-K LTR-SF-K LTL-RF-K LTR-RF-K LEFT LT1-LINK RIGHT LT1-LINK LT1-PROTECT2

Left Right Left Right 1 Extra Link 1 Extra Link Left Right

Extra Left Extra Right Extra Left Extra Right 2 Extra Links 2 Extra Links Extra Left Extra Right

3 Extra Links 3 Extra Links

4 Extra Links 4 Extra Links

Both hardware styles in Section A are width adjustable. Cover wraps around hardware and closes with hook and loop attachment.


BODILINK HEAD SUPPORT & HARDWARE5

COMFORT TEK FOR FLUID PROTECTION & AN EASILY CLEANED

SURFACE.

FOR AIR TRANSMISSION & HEAT DISSIPATION.

STRETCH AIR

FOR SKIN PROTECTION & SHEAR REDUCTION. NOT FLUID RESISTANT.

L

L

L

L

L

W

W

5.2 PAD COVER MATERIAL

GlideWear® (GLIDEWEAR)

Comfort-Tek (COMFORT-TEK)

Stretch-Air (STRETCH-AIR)

Pad Firmness

6W x 3½LSoft BL-HSP1-6W3L

Extra Soft BL-HSP2-6W3L

8W x 4LSoft BL-HSP1-8W4L


10W x 5Lwith adjustable wings

Soft BL-HSP1-10W5L



Soft BL-HSP1-14W5L



Soft BL-HSP1-18W5L


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

HEAD SUPPORT PAD STYLEHCPCS CODING: E0955 MSRP $230.00

5.1

5.3 HEAD SUPPORT HARDWARE & BRACKETHCPCS CODING: E1028

Patent Pending

Extra Link

Extra Spacer Plate

¼”

HEAD SUPPORT HARDWARE MSRP $221.00/ea.

MSRP $35.00/extra link or spacer each

Removable Hardware* (BL-HSH-FX)

Extra Link (BL-HSH-LINK)

Extra Spacer Plate (BL-HSH-SPCR)

3 ¼”

HEAD SUPPORT BRACKET & HARDWARE MSRP $286.07

HEAD SUPPORT BRACKET ONLY*MSRP $146.77/ea.

14W Bracket and Hardware (BL-HSH-FX-AR14W)




14W Bracket Only (HSH-AR14W)




*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 Back Supports

Required when using COMPASS® 4 hardware (2 or 4 POINT)


ADDITIONAL INFORMATION66.1 COMMENTS

INSTRUCTIONS:

Please reference any section or subsection of the form when commenting.

INSTRUCTIONS:

Section # Page # COMMENTS

If preferred, please sketch ideas in the spaces provided below.

SUBMIT BY EMAIL

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