CUSTOM ACTA-BACK - FULL ORDER FORM HCPCS CODE: E2617

Transcription

1 CUSTOM ACTA-BACK - FU DER FM HCPCS CODE: E2617 CUSTOMER/PATIENT INFMATION 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 to customs@comfortcompany.com or print and fax to Date: Company Name/ACCT #: Patient Name: Patient Weight: Patient Height: Patient Reference: W/C Manufacturer: Model #: Serial #: P.O. Number: Requested By: Phone: Ship To: Additional Information: Fax: Seat Frame Width: Seat Frame Depth: Seat Rail Tube Size: SEATING SYSTEM MEASUREMENTS B A Seating system measurements do not affect any selections made through the order form. H C D A - Back Support Width B - Back Support ength C - Width Between ateral Trunk Supports D - Width Between ateral Thigh Supports E - Seat Width F - Seat Depth G - Effective Seat Depth H - ateral Trunk Support Height F E G 509 S. 22ND AVENUE BOZEMAN, MT PH FAX COMFTCOMPANY.COM 1/10

2 1 CUSTOM ACTA-BACK SIZE & COVER MATERIA 1.1 BACK SUPPT SIZE HCPCS CODE: E2617 EXAMPE OF ACTA-BACK GEOMETRY 12 WIDTH Select the desired back support size clicking on the corresponding box below or filling in the specific width and length measurements in the Custom Back Part Number box. 14 WIDTH 16 WIDTH 18 WIDTH 20 WIDTH 22 WIDTH 24 WIDTH ENGTH 14 ENGTH 16 ENGTH 18 ENGTH 20 ENGTH 22 ENGTH $ *ength () refers to the actual size dimension of the support from bottom to top edge. C-A-10W22H C-A-12W22H C-A-14W22H C-A-16W22H C-A-18W22H C-A-20W22H C-A-22W22H C-A-24W22H C-A-26W22H C-A-28W22H C-A-10W20H C-A-12W20H C-A-14W20H C-A-16W20H C-A-18W20H C-A-20W20H C-A-22W20H C-A-24W20H C-A-26W20H C-A-28W20H ENGTH* C-A-10W18H C-A-12W18H C-A-14W18H C-A-16W18H C-A-18W18H C-A-20W18H C-A-22W18H C-A-24W18H C-A-26W18H C-A-28W18H C-A-10W16H C-A-12W16H C-A-14W16H C-A-16W16H C-A-18W16H C-A-20W16H C-A-22W16H C-A-24W16H C-A-26W16H C-A-28W16H C-A-10W14H C-A-12W14H C-A-14W14H C-A-16W14H C-A-18W14H C-A-20W14H C-A-22W14H C-A-24W14H C-A-26W14H C-A-28W14H C-A-10W12H C-A-12W12H C-A-14W12H C-A-16W12H C-A-18W12H C-A-20W12H C-A-22W12H C-A-24W12H C-A-26W12H C-A-28W12H C-A-10W10H C-A-12W10H C-A-14W10H C-A-16W10H C-A-18W10H C-A-20W10H C-A-22W10H C-A-24W10H C-A-26W10H C-A-28W10H $ $ $ FRAME WIDTH Custom Back Support Part Number: C - A - W H Desired back support length is H dimension in part number above Width / ength = $923 Base Price Width / ength = $1014 Base Price Width / ength = $1043 Base Price Width / ength = $1497 Base Price *If desired size is not listed above, a 60% up charge will be applied for materials. 1.2 COVER MATERIA OPTIONS * REQUIRED * 1.3 MIITARY BRANCH PATCH (OPTIONA) STRETCH-AIR TM Stretch-Air has comfortable stretch, air transmission and heat dissipation. It is not fluid resistant. - - COMFT-TEK TM Comfort-Tek is a smooth, easily cleaned surface. The fluid protection aids in infection control. - WITH - DIAMOND DIGI-CAMO ACCENT FABRIC Choose either DIAMOND or DIGI-CAMO accent fabric. Care for each fabric is identical. COVER FABRIC STRETCH-AIR COMFT-TEK ACCENT FABRIC DIAMOND STRETCH-AIR) DIGI-CAMO DIGI-STRETCH-AIR) DIAMOND COMFT-TEK) DIGI-CAMO DIGI-COMFT-TEK) Cover appearance may vary with hardware selection. Patch Placement AIR FCE AIR-FCE-PATCH) ARMY ARMY-PATCH) MARINES MARINES-PATCH) NAVY NAVY-PATCH) 2/10

3 2 FOAM OPTIONS 2.1 CUSTOM FOAM SEECTION Select only one type of foam per layer. A minimum of one layer must be chosen if Foam in Place is not selected in Section 2.2. Indicates standard Acta-Back foam configuration. May use as a reference when choosing foam layers. REAR AYER (REQUIRED) H.R. Viscool & Visco MSRP $ MIDDE AYER (OPTIONA) H.R. Viscool & Visco MSRP $ TOPPER AYER (OPTIONA) H.R. Viscool & Visco MSRP $ ¼ Crosslink foundation layer will come standard on all back supports. REAR AYER MIDDE AYER TOPPER AYER For other foam combinations call Customer Service FOAM TYPE H.R. Medium H.R. ¼ ½ ¾ 1 1¼ ¼ ½ ¾ 1 1¼ ¼ ½ ¾ 1 1¼ HRM-0.25) HRS-0.25) HRM-0.50) HRS-0.50) HRM-0.75) HRS-0.75) HRM-1.00) HRS-1.00) HRM-1.25) HRS-1.25) HRM-0.25) HRS-0.25) HRM-0.50) HRS-0.50) HRM-0.75) HRS-0.75) HRM-1.00) HRS-1.00) HRM-1.25) HRS-1.25) HRM-0.25) HRS-0.25) HRM-0.50) HRS-0.50) HRM-0.75) HRS-0.75) HRM-1.00) HRS-1.00) HRM-1.25) HRS-1.25) MSRP $ Viscool TM Medium Viscool TM Viscool TM X- Visco XX- VIS-M-0.50) VIS-S-0.50) VIS-XS-0.50) Rear-VIS- XXS-0.50) VIS-M-1.00) VIS-S-1.00) VIS-XS-1.00) Rear-VIS- XXS-1.00) VIS-M-0.50) VIS-S-0.50) VIS-XS-0.50) Mid-VIS- XXS-0.50) VIS-M-1.00) VIS-S-1.00) VIS-XS-1.00) Mid-VIS- XXS-1.00) VIS-M-0.50) VIS-S-0.50) VIS-XS-0.50) Top-VIS- XXS-0.50) VIS-M-1.00) VIS-S-1.00) VIS-XS-1.00) Top-VIS- XXS-1.00) FOAM IN PACE KIT 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 KIT INCUDES: (Note: Price of Viscool layers will be added to the order separately.) Back cushion cover with an optional 3 or 4 deep back, with a stretchy, pleated contact surface to allow for foam growth. Two aluminum stays sewn into the rear of the cover which can be molded to support spinal curvature prior to pouring FIP Chemicals. 1 of Viscool TM 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 padding, prior to pouring the foam. Aluminum Stays 1 Viscool Medium Gap for Foam in Place ½ Viscool ½ of Viscool TM 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. Two plastic bags are included to contain the foam chemicals as they expand. Pleates 3-4 Border BDER Thickness BAG POUR SIZE RECOMMENDATION CHART 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 EXTRA SOFT MEMY FOAM 1 Bag FIP MSRP: $ ½ Bag FIP MSRP: $ BACK BDER POUR SIZE 4 BACK BDER SOFT MEMY FOAM 1 Bag FIP MSRP: $ ½ Bag FIP MSRP: $ BACK BDER POUR SIZE 4 BACK BDER MEDIUM MEMY FOAM 1 Bag FIP MSRP: $ ½ Bag FIP MSRP: $ BACK BDER POUR SIZE 4 BACK BDER FIP3-1-XS) 1 BAG FIP4-1-XS) FIP3-1-S) 1 BAG FIP4-1-S) FIP3-1-M) 1 BAG FIP4-1-M) FIP3-1.5-XS) 1 ½ BAG FIP4-1.5-XS) FIP3-1.5-S) 1 ½ BAG FIP4-1.5-S) FIP3-1.5-M) 1 ½ BAG FIP4-1.5-M) 3/10

4 3 BACK SUPPT OPTIONS 3.1 MODABE AUMINUM STAYS A standard alignment has been optimized based on back support width if you choose not to select a specific width between the stays. Select the spacing between the moldable aluminum stays. Custom options are available by selecting your desired spacing below. SPACE BETWEEN STAYS This back support comes with two patented aluminum stays that can be molded to support spinal curvature. Stays are offset from the spine and are held in place by pockets sewn into the rear of the cover. The stays are accessible while the user is seated against the back support through the zipper located at the top of the back support. FRONT VIEW A Moldable Aluminum Stays Aluminum Stay Pockets Moldable Aluminum Stays A =1 STAY-1.0) A =1 ½ STAY-1.5) A = 2 (Standard Alignment) STAY-2.0) A = 2 ½ STAY-2.5) A = 3 STAY-3.0) A = 3 ½ STAY-3.5) A = 4 STAY-4.0) A = 4 ½ STAY-4.5) Specify Custom Spacing STAY-OTHER) None STAY-NONE) 3.2 HARDWARE OPTIONS 4 Point hardware may not fit all smaller back support lengths. 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 QUICK REEASE (2 POINTS OF ATTACHMENT) Quick Release ever for Removal Quick Release (2 point) Q-COMPASS) Compass Bundle COMPASS-BUNDE) 3.3 CO (OPTIONA) COMPASS 4 QUICK REEASE (4 POINTS OF ATTACHMENT) 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. 4 POINT TOP VIEW Quick Release (4 point) Q-COMPASS4) COMPASS 4 FIXED (2 POINTS OF ATTACHMENT) Bolts Together COMPASS 4 BUNDE MSRP $ (2 PT, 4 PT, FIXED & QUICK REEASE) A. Fixed (2 point) NQ-COMPASS) COMPASS 4 FIXED (4 POINTS OF ATTACHMENT) 4 POINT TOP VIEW 3.4 EMBROIDERY (OPTIONA) Fill out Sections A, B, & C. THREAD CO OPTIONS Red EMB-RED) Purple EMB-PURPE) Blue EMB-BUE) Green EMB-GREEN) Fixed (4 point) NQ-COMPASS4) *Power Mount Bracket required for all power chairs listed below. 3.5 COMPASS POWER MOUNT BRACKET MSRP $ (Not available on back supports smaller than 12 or 12 W, or sizes 12Wx16 & 12Wx18) *Using Compass Power Mount on Rovi requires mounting to the RECESSED PANAR INTERFACE PATE available when ordering the Motion Concepts Seating System. Drilling is required for mounting. Quantum w/ Tru Balance 3 PMB-QUANTUM) Permobil w/ Corpus 3G PMB-PERMOBI) Quickie w/ 3.7 Power PMB-QUICKIE) Avid Rehab w/ Power T & R PMB-AVID) Rovi w/ Motion Concepts* PMB-ROVI) PRIVACY FAP (OPTIONA) MSRP $35.00 This flap connects with hook & loop attachment between the seat and back support for added privacy. Color ocation B. Pink EMB-PINK) Silver EMB-SIVER) FONT/STYE OPTIONS Helvetica EMB-Helvetica) EMB-Twilight) Placement of the piping may vary by back support size and mounting hardware. Red RED) Purple PURPE) Blue BUE) Green GREEN) C. Garamond EMB-Garamond) WD ONE - AND/ - EMB-Script) Privacy Flap Pink PINK) Remove REMOVE) WD TWO Privacy Flap PF-CV) Orange ANGE) 4/10

5 4 BODIINK ATERA TRUNK SUPPT & HARDWARE 4.1 BASIC PAD SIZE & SHAPE HCPCS Code: E0956 MSRP $82.00/ea. You may make one selection per column (eft, Extra eft, Right, and Extra Right) in section 4.1. Follow each column down to sections 4.2 and 4.3 and select a style and cover for each pad selected in section 4.1. Premium pads in section 4.4 on next page. 4.2 *ength () refers to the actual size dimension of the support from top to bottom edge. Depth (D) refers to the actual size dimension from anterior to posterior edge. SUPPTIVE ACTIVE Contact Customer Support for custom sizes BASIC PAD STYE /ea. SHAPE SIZE EFT *EXTRA EFT RIGHT *EXTRA RIGHT SUPPTIVE ACTIVE D D 3 x 4 D B-TSP1S-34D-H B-TSP1S-34D-H B-TSP1S-34D-RH B-TSP1S-34D-RH 3 x 5 D B-TSP1S-35D-H B-TSP1S-35D-H B-TSP1S-35D-RH B-TSP1S-35D-RH 4 x 5 D B-TSP1S-45D-H B-TSP1S-45D-H B-TSP1S-45D-RH B-TSP1S-45D-RH 4 x 6 D B-TSP1S-46D-H B-TSP1S-46D-H B-TSP1S-46D-RH B-TSP1S-46D-RH 5 x 7 D B-TSP1S-57D-H B-TSP1S-57D-H B-TSP1S-57D-RH B-TSP1S-57D-RH 6 x 6 D B-TSP1S-66D-H B-TSP1S-66D-H B-TSP1S-66D-RH B-TSP1S-66D-RH 3 x 4 D B-TSP1A-34D-H B-TSP1A-34D-H B-TSP1A-34D-RH B-TSP1A-34D-RH 3 x 5 D B-TSP1A-35D-H B-TSP1A-35D-H B-TSP1A-35D-RH B-TSP1A-35D-RH 4 x 5 D B-TSP1A-45D-H B-TSP1A-45D-H B-TSP1A-45D-RH B-TSP1A-45D-RH 4 x 6 D B-TSP1A-46D-H B-TSP1A-46D-H B-TSP1A-46D-RH B-TSP1A-46D-RH 5 x 7 D B-TSP1A-57D-H B-TSP1A-57D-H B-TSP1A-57D-RH B-TSP1A-57D-RH 6 x 6 D B-TSP1A-66D-H B-TSP1A-66D-H B-TSP1A-66D-RH B-TSP1A-66D-RH MODABE RIGID * EXTRA parts may not fit depending on back support, pad, and hardware size and style combinations. Please contact customer support with questions. STYE OPTIONS EFT *EXTRA EFT RIGHT *EXTRA RIGHT MODABE TS-P1-MOD TS-P1-MOD TS-P1-MOD TS-P1-MOD RIGID TS-P1-RIGID TS-P1-RIGID TS-P1-RIGID TS-P1-RIGID 4.3 BASIC PAD COVER /ea. COVER OPTIONS EFT *EXTRA EFT RIGHT *EXTRA RIGHT COMFT-TEK TS-P1-COMFT TS-P1-COMFT TS-P1-COMFT TS-P1-COMFT STRETCH-AIR TS-P1-STRETCH TS-P1-STRETCH TS-P1-STRETCH TS-P1-STRETCH COMFT-TEK F FUID PROTECTION & AN EASIY CEANED SURFACE. STRETCH-AIR F AIR TRANSMISSION & HEAT DISSIPATION. 5/10

6 4.4 PREMIUM PAD SIZE & SHAPE HCPCS Code: E0956 MSRP $88.00/ea. You may make one selection per column (eft, Extra eft, Right, and Extra Right) in section 4.4. Follow each column down to sections 4.5 and 4.6 and select a style and cover for each pad selected in section 4.4. *ength () refers to the dimension of the support from top to bottom edge. Depth (D) refers to the dimension of the support from anterior to posterior edge. SHAPE SIZE EFT *EXTRA EFT RIGHT *EXTRA RIGHT 3 x 4 D B-TSP2S-34D-H B-TSP2S-34D-H B-TSP2S-34D-RH B-TSP2S-34D-RH SUPPTIVE SUPPTIVE D 3 x 5.5 D B-TSP2S-35D-H B-TSP2S-35D-H B-TSP2S-35D-RH B-TSP2S-35D-RH 4 x 5 D B-TSP2S-45D-H B-TSP2S-45D-H B-TSP2S-45D-RH B-TSP2S-45D-RH 4 x 6.5 D B-TSP2S-46D-H B-TSP2S-46D-H B-TSP2S-46D-RH B-TSP2S-46D-RH 5 x 6.5 D B-TSP2S-56D-H B-TSP2S-56D-H B-TSP2S-56D-RH B-TSP2S-56D-RH 6 x 6.5 D B-TSP2S-66D-H B-TSP2S-66D-H B-TSP2S-66D-RH B-TSP2S-66D-RH 3 x 4 D B-TSP2A-34D-H B-TSP2A-34D-H B-TSP2A-34D-RH B-TSP2A-34D-RH ACTIVE 3 x 5.5 D B-TSP2A-35D-H B-TSP2A-35D-H B-TSP2A-35D-RH B-TSP2A-35D-RH ACTIVE 4 x 5 D B-TSP2A-45D-H B-TSP2A-45D-H B-TSP2A-45D-RH B-TSP2A-45D-RH 4 x 6.5 D B-TSP2A-46D-H B-TSP2A-46D-H B-TSP2A-46D-RH B-TSP2A-46D-RH D 5 x 6.5 D B-TSP2A-56D-H B-TSP2A-56D-H B-TSP2A-56D-RH B-TSP2A-56D-RH 6 x 6.5 D B-TSP2A-66D-H B-TSP2A-66D-H B-TSP2A-66D-RH B-TSP2A-66D-RH 4.5 PREMIUM PAD STYE /ea. MODABE RIGID * EXTRA parts may not fit depending on back support, pad, and hardware size and style combinations. Please contact customer support with questions. STYE OPTIONS EFT *EXTRA EFT RIGHT *EXTRA RIGHT MODABE TS-P2-MOD TS-P2-MOD TS-P2-MOD TS-P2-MOD RIGID TS-P2-RIGID TS-P2-RIGID TS-P2-RIGID TS-P2-RIGID 4.6 PREMIUM PAD COVER COVER OPTIONS MSRP EFT *EXTRA EFT RIGHT *EXTRA RIGHT NO COVER $0.00/ea. TS-P2-NO-CV TS-P2-NO-CV TS-P2-NO-CV TS-P2-NO-CV COMFT-TEK $0.00/ea. TS-P2-COMFT TS-P2-COMFT TS-P2-COMFT TS-P2-COMFT STRETCH-AIR $0.00/ea. TS-P2-STRETCH TS-P2-STRETCH TS-P2-STRETCH TS-P2-STRETCH GIDEWEAR $13.00/ea. TS-P2-GIDE TS-P2-GIDE TS-P2-GIDE TS-P2-GIDE COMFT-TEK with FOAM $13.00/ea. TS-P2-COMFT-FM TS-P2-COMFT-FM TS-P2-COMFT-FM TS-P2-COMFT-FM STRETCH-AIR with FOAM $13.00/ea. TS-P2-STRETCH-FM TS-P2-STRETCH-FM TS-P2-STRETCH-FM TS-P2-STRETCH-FM GIDEWEAR with FOAM $26.00/ea. TS-P2-GIDE-FM TS-P2-GIDE-FM TS-P2-GIDE-FM TS-P2-GIDE-FM COMFT-TEK F FUID PROTECTION & AN EASIY CEANED SURFACE. STRETCH-AIR F AIR TRANSMISSION & HEAT DISSIPATION. F SKIN PROTECTION & SHEAR REDUCTION. NOT FUID RESISTANT. COVER with FOAM F SOFT FEE, NON-ZERO CUSHIONING SUPPT. 6/10

7 4.7 GT MOUNTING HARDWARE * EXTRA parts may not fit depending on back support, pad, and hardware size and style combinations. Both Fixed and Swing-Away hardware styles are adjustable. Release Button SWING-AWAY Open Position FIXED You may make one selection per column (eft, Extra eft, Right, and Extra Right) in section 4.7. GT and GT2 Hardware and Pad styles are interchangeable. GT hardware extra links (section 4.8) will only work with GT style hardware. SOT MOUNTING MSRP EFT *EXTRA EFT RIGHT *EXTRA RIGHT SWING-AWAY HCPCS Code: E1028 $271.00/ea. B-TS-GT1SAS-H B-TS-GT1SAS-H B-TS-GT1SAS-RH B-TS-GT1SAS-RH FIXED $129.00/ea. B-TS-GT1FXS-H B-TS-GT1FXS-H B-TS-GT1FXS-RH B-TS-GT1FXS-RH 4.8 GT ADDITIONA OPTIONS 1 EXTRA HARDWARE INKS EFT ADD EFT RIGHT ADD RIGHT MSRP $37.00/link B-TS-GT1INK B-TS-GT1INK B-TS-GT1INK B-TS-GT1INK HARDWARE COVER EFT *EXTRA EFT RIGHT EXTRA RIGHT MSRP $26.00/ea B-TS-HCOVER B-TS-HCOVER B-TS-HCOVER B-TS-HCOVER 4.9 GT2 MOUNTING HARDWARE Both Fixed and Swing-Away hardware styles are adjustable. Swing-Away Shown Release Button SOT MOUNT Open Position Fixed Shown **TRACK MOUNT Swing-Away Shown Release Button You may make one selection per column in section 4.9. **TRACK MOUNT is only available when using Compass 4 Hardware. If using Compass Power Mount hardware, select slot mounting lateral hardware. Extra Track Mount Hardware does not come with an extra track Extra links and long mounting bracket (section 4.10) only for GT2 style hardware. SOT MOUNTING MSRP EFT *EXTRA EFT RIGHT *EXTRA RIGHT SWING-AWAY HCPCS Code: E1028 $298.00/ea. B-TS-GT2SAS-H B-TS-GT2SAS-H B-TS-GT2SAS-RH B-TS-GT2SAS-RH FIXED $178.00/ea. B-TS-GT2FXS-H B-TS-GT2FXS-H B-TS-GT2FXS-RH B-TS-GT2FXS-RH **TRACK MOUNTING MSRP EFT *EXTRA EFT RIGHT *EXTRA RIGHT SWING-AWAY HCPCS Code: E1028 $298.00/ea. B-TS-GT2SAT-H B-TS-GT2SATX-H B-TS-GT2SAT-RH B-TS-GT2SATX-RH FIXED $178.00/ea. B-TS-GT2FXT-H B-TS-GT2FXTX-H B-TS-GT2FXT-RH B-TS-GT2FXTX-RH 4.10 GT2 ADDITIONA OPTIONS 1¼ EXTRA HARDWARE INKS EFT ADD EFT RIGHT ADD RIGHT MSRP $37.00/link B-TS-GT2INK B-TS-GT2INK B-TS-GT2INK B-TS-GT2INK ONG MOUNTING BRACKET EFT *EXTRA EFT RIGHT *EXTRA RIGHT adds 1 of adjustment per bracket For Slot Mount MSRP $37.00/ea B-TS-GT2SOT-H B-TS-GT2SOT-H B-TS-GT2SOT-RH B-TS-GT2SOT-RH HARDWARE COVER EFT *EXTRA EFT RIGHT *EXTRA RIGHT MSRP $26.00/ea B-TS-HCOVER B-TS-HCOVER B-TS-HCOVER B-TS-HCOVER 7/10

8 5.1 5 BODIINK HEAD SUPPT HARDWARE & PADS PREMIUM PAD SIZE HCPCS CODING: E0955 MSRP $ W 6W x 3 8W x 4 10W x 5 with adjustable wings 12W x 5 with adjustable wings 14W x 5 with adjustable wings 18W x 5 with adjustable wings Pad Firmness Extra Extra Extra Extra Extra Extra ength () refers to the actual size dimension of the support from bottom to top edge. B-HSP1-6W3 B-HSP2-6W3 B-HSP1-8W4 B-HSP2-8W4 B-HSP1-10W5 B-HSP2-10W5 B-HSP1-12W5 B-HSP2-12W5 B-HSP1-14W5 B-HSP2-14W5 B-HSP1-18W5 B-HSP2-18W5 Premium Head Support Pads angles can be formed by adjusting the plates in the pad. You may make one selection per column. Choose between premium (5.1) -or- basic (5.3). Choose 14W a x 5 cover Head material Support Pad in 5.2 Pictured -or PREMIUM PAD COVER MATERIA COMFT-TEK F FUID PROTECTION & AN EASIY CEANED SURFACE. STRETCH-AIR F SKIN PROTECTION & SHEAR REDUCTION. NOT FUID RESISTANT. F AIR TRANSMISSION & HEAT DISSIPATION. GlideWear (GIDEWEAR) (add $26.00) Comfort-Tek (COMFT-TEK) Stretch-Air (STRETCH-AIR) W 5.3 BASIC PAD SIZE HCPCS CODING: E0955 MSRP $ ength () refers to the actual size dimension of the support from bottom to top edge. 5.4 BASIC PAD COVER MATERIA W 6W x 5 B-HSP3-6W5 COMFT-TEK F FUID PROTECTION & AN EASIY CEANED SURFACE. 8W x 5 B-HSP3-8W5 STRETCH-AIR F AIR TRANSMISSION & HEAT DISSIPATION. 10W x 6 12W x 6 B-HSP3-10W6 B-HSP3-12W6 Basic head support pads can be formed to any shape using the moldable steel insert inside the pad. Comfort-Tek (COMFT-TEK) Stretch-Air (STRETCH-AIR) 14W x 6 B-HSP3-14W6 18W x 6 B-HSP3-18W6 5.5 A. PT HARDWARE, MID 6 W HEAD SUPPT HARDWARE HCPCS CODING: E1028 PT HARDWARE, REMOVABE PT HARDWARE, AT 6 PT HARDWARE, MID 8 SIZE & SHAPE MSRP PART NUMBER MID 6 $ (B-HS-PT1RMMID6) AT 6 $ (B-HS-PT1RMAT6) MID 8 $ (B-HS-PT1RMMID8) AT 8 $ (B-HS-PT1RMAT8) MAX 8* $ (B-HS-PT1RMMAX8) PT HARDWARE, AT 8 You may make one selection per column in either A -or- B. If choosing 5.5 A, choose a stem length option next. Choose which mounting block option you require in 5.6. PT HARDWARE, MAX 8 *Provides the greatest amount of articulation and range of motion. PT HARDWARE RANGE OF MOTION PT MODE TOTA # OF INKS TOTA INK ENGTH ANTERI POSTERI ATERA MID N/A AT MID N/A AT MAX /10

9 PT HARDWARE, REMOVABE (CONTINUED) PT HARDWARE, STEM ENGTH OPTION STANDARD PT STEM, 7 PT STEM, 3 B. 5.6 STEM ENGTH MSRP PART NUMBER STANDARD 7 STEM $0.00 (HS-STEM-7) **3 STEM $0.00 (HS-STEM-3) GT HARDWARE, REMOVABE GT HARDWARE, ATERA GT HARDWARE, MID-INE HEAD SUPPT MOUNTING OPTION **3 Stem is recommended for use with power mounting where there may be special constraints with power chair functions GT HARDWARE RANGE OF MOTION GT MODE TOTA # OF INKS TOTA INK ENGTH ANTERI SIZE & SHAPE MSRP PART NUMBER ATERA $ (B-HS-GT3RMAT) MID-INE $ (B-HS-GT3RMMID) POSTERI ATERA AT MID N/A MOUNTING BOCK BRACKET MSRP PART NUMBER MOUNTING BOCK- POSTERI A POSTERI A MOUNTING BOCK $0.00 (HS-MB-POSTA) 5.7 EXTRA HARDWARE INK ENGTH MSRP EXTRA PART *EXTRA 2 INK $57.00 (B-HS-PT1INK2) *EXTRA 3 INK $57.00 (B-HS-PT1INK3) *EXTRA 4 INK $57.00 (B-HS-PT1INK4) TOO-ESS WING OCK MSRP EXTRA PART EXTRA PART EXTRA PART EXTRA PART *1 OCK $21.00/each (B-HS-52WINGA1) (B-HS-52WINGA1) (B-HS-52WINGA1) (B-HS-52WINGA1) ADDITIONA MSRP EXTRA PART 1/4 SPACER PATE $37.00/each (B-HS-SPCRA) *F PT HARDWARE ONY 9/10

10 6 ADDITIONA INFMATION 6.1 COMMENTS Please reference any section or subsection of the form when commenting. Section # Page # COMMENTS SUBMIT BY EMAI If preferred, please sketch ideas in the spaces provided below. 10/10