CUSTOM ACTA-EMBRACE BACK - SHORT ORDER FORM HCPCS CODE: E2617

Transcription

1 CUSTOM ACTA-EMBRACE BACK - SHORT ORER FORM HCPCS COE: E2617 Company Name/ACCT #: P.O. Number: Requested By: Phone: Ship To: Patient Reference: Fax: 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 BACK SUPPORT SIZE HCPCS Code: E2617 C - E - W H 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. NOTE: esired back support length is H dimension in part number above. Cover appearance may vary with hardware selection and size. 2 COVER OPTIONS Choose either Stretch-Air or Comfort-Tek cover fabric with iamond or igi-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. STRETCH-AIR W/ IAMON (C-STRETCH-AIR) COMFORT-TEK W/ IAMON (C-COMFORT-TEK) STRETCH-AIR W/ IGI-CAMO (C-IGI-STRETCH-AIR) COMFORT-TEK W/ IGI-CAMO (C-IGI-COMFORT-TEK) 3 MIITARY BRANCH PATCH (OPTIONA) ARMY 4 CUSTOM FOAM SEECTION AIR FORCE MARINES NAVY (C-AIR-FORCE-PATCH) (C-ARMY-PATCH) (C-MARINES-PATCH) (C-NAVY-PATCH) 1 (C-TOP-VIS-XXS-1.00) SFC 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. = SFC = Standard Foam Configuration. Use as a reference when choosing foam layers. Rear ayer Middle ayer Topper ayer REAR AYER (REQUIRE) MIE AYER (OPTIONA) TOPPER AYER (OPTIONA) H.R. MEIUM H.R. MEIUM H.R. MEIUM 1/4 (C-REAR-HRM-0.25) 1/2 (C-REAR-HRM-0.50) 3/4 (C-REAR-HRM-0.75) SFC 1 (C-REAR-HRM-1.00) 1 1/4 (C-REAR-HRM-1.25) 1/4 (C-MI-HRM-0.25) 1/2 (C-MI-HRM-0.50) 3/4 (C-MI-HRM-0.75) 1 (C-MI-HRM-1.00) 1 1/4 (C-MI-HRM-1.25) 1/4 (C-TOP-HRM-0.25) 1/2 (C-TOP-HRM-0.50) 3/4 (C-TOP-HRM-0.75) 1 (C-TOP-HRM-1.00) 1 1/4 (C-TOP-HRM-1.25) H.R. H.R. H.R. 1/4 (C-REAR-HRS-0.25) 1/2 (C-REAR-HRS-0.50) 3/4 (C-REAR-HRS-0.75) 1 (C-REAR-HRS-1.00) 1 1/4 (C-REAR-HRS-1.25) 1/4 (C-MI-HRS-0.25) 1/2 (C-MI-HRS-0.50) 3/4 (C-MI-HRS-0.75) 1 (C-MI-HRS-1.00) 1 1/4 (C-MI-HRS-1.25) 1/4 (C-TOP-HRS-0.25) 1/2 (C-TOP-HRS-0.50) 3/4 (C-TOP-HRS-0.75) 1 (C-TOP-HRS-1.00) 1 1/4 (C-TOP-HRS-1.25) VISCOO TM MEIUM VISCOO TM MEIUM VISCOO TM MEIUM 1/2 (C-REAR-VIS-M-0.50) 1 (C-REAR-VIS-M-1.00) 1/2 (C-MI-VIS-M-0.50) 1 (C-MI-VIS-M-1.00) 1/2 (C-TOP-VIS-M-0.50) 1 (C-TOP-VIS-M-1.00) VISCOO TM VISCOO TM VISCOO TM 1/2 (C-REAR-VIS-S-0.50) 1 (C-REAR-VIS-S-1.00) 1/2 (C-MI-VIS-S-0.50) 1 (C-MI-VIS-S-1.00) 1/2 (C-TOP-VIS-S-0.50) 1 (C-TOP-VIS-S-1.00) VISCOO TM $ VISCOO TM VISCOO TM 1/2 (C-REAR-VIS-XS-0.50) 1 (C-REAR-VIS-XS-1.00) 1/2 (C-MI-VIS-XS-0.50) 1 (C-MI-VIS-XS-1.00) 1/2 (C-TOP-VIS-XS-0.50) 1 (C-TOP-VIS-XS-1.00) VISCO EXTRA 1/2 (C-REAR-VIS-XXS-0.50) 1 (C-REAR-VIS-XXS-1.00) 5 FOAM IN PACE KIT BORER Thickness BAG POUR SIZE RECOMMENATION CHART FRAME WITH RECOMMENE 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 MEMORY FOAM 3 BACK BORER 1 BAG (C-FIP3-1-XS) 1 1/2 BAG (C-FIP3-1.5-XS) 4 BACK BORER 1 BAG (C-FIP4-1-XS) 1 1/2 BAG (C-FIP4-1.5-XS) Pleates 3-4 Border VISCO EXTRA Aluminum Stays 1 Viscool Medium Gap for Foam in Place ½ Viscool Soft 1/2 (C-MI-VIS-XXS-0.50) 1 (C-MI-VIS-XXS-1.00) KIT INCUES: 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.) MEMORY FOAM 3 BACK BORER 1 BAG (C-FIP3-1-S) 1 1/2 BAG (C-FIP3-1.5-S) 4 BACK BORER 1 BAG (C-FIP4-1-S) 1 1/2 BAG (C-FIP4-1.5-S) VISCO EXTRA 1/2 (C-TOP-VIS-XXS-0.50) SFC 1 (C-TOP-VIS-XXS-1.00) MEIUM MEMORY FOAM 3 BACK BORER 1 BAG (C-FIP3-1-M) 1 1/2 BAG (C-FIP3-1.5-M) 4 BACK BORER 1 BAG (C-FIP4-1-M) 1 1/2 BAG (C-FIP4-1.5-M) Standard foam layer thicknesses reduce to 3/8 on sizes /5

2 6 MOABE AUMINUM STAYS SPACE BETWEEN STAYS 1 (C-STAY-1.0) 1 1/2 (C-STAY-1.5) 2 (C-STAY-2.0) 2 1/2 (C-STAY-2.5) 3 (C-STAY-3.0) 3 1/2 (C-STAY-3.5) 4 (C-STAY-4.0) 4 1/2 (C-STAY-4.5) SPECIFY CUSTOM SPACING (C-STAY-OTHER) NONE (C-STAY-NONE) 7 BACK SUPPORT WING STYE (Extra Wings $69.00ea.) Contoured wings are needed to mount ateral Trunk Supports and Winter/Summer Hardware. Both styles of wing are height and width adjustable CONTOURE WING Wing ength Moldable Aluminum Stays Aluminum Stay Pockets 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. *ength () refers to the actual size dimension of the support from bottom to top edge. WING SIZE RECOMMENATION CHART Back ength SIZE 5 (C-WING-5-CON) 6 (C-WING-6-CON) 8 (C-WING-8-CON) EXTRA 5 (C-A--WING-5-CON) 6 (C-A--WING-6-CON) 8 (C-A--WING-8-CON) Wing ength Back 5 Wing Back 6 Wing Back 8 Wing 5 (C-WING-5-CON) 6 (C-WING-6-CON) 8 (C-WING-8-CON) 8 HARWARE OPTIONS COMPASS 4 MOUNTING HARWARE 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 REEASE COMPASS 4 (2 PT) (C-Q-COMPASS) QUICK REEASE COMPASS 4 (4 PT) (C-Q-COMPASS4) FIXE COMPASS 4 (2 PT) (C-NQ-COMPASS) FIXE COMPASS 4 (4 PT) (C-NQ-COMPASS4) 9 COOR COOR COOR OCATION COMPASS 4 BUNE $ (2 PT, 4 PT, QUICK REEASE & FIXE) (C-COMPASS-BUNE) COMPASS POWER MOUNT BRACKET 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 or 12 W. *Power Mount Bracket required for all power chairs listed below. QUANTUM with TRU BAANCE 3 (C-PMB-QUANTUM) PERMOBI with CORPUS 3G (C-PMB-PERMOBI) QUICKIE with 3.7 POWER (C-PMB-QUICKIE) AVI REHAB with POWER T & R (C-PMB-AVI) ROVI with MOTION CONCEPTS* (C-PMB-ROVI) *Using Compass Power Mount on Rovi requires mounting to the RECESSE PANAR INTERFACE PATE available when ordering the Motion Concepts Seating System. rilling is required for mounting. RE (C-RE) PURPE (C-PURPE) PINK (C-PINK) BUE (C-BUE) GREEN (C-GREEN) ORANGE (C-ORANGE) REMOVE (C-REMOVE) Accent colors are applied via colored piping. If no color is selected, our standard reflective piping will be used. INEAR WING Wing ength EXTRA 5 (C-A-R-WING-5-CON) 6 (C-A-R-WING-6-CON) 8 (C-A-R-WING-8-CON) SIZE 5 (C-WING-5-IN) 6 (C-WING-6-IN) 8 (C-WING-8-IN) EXTRA 10 EMBROIERY A. THREA COOR OPTIONS B. FONT STYE OPTIONS RE (C-EMB-RE) PURPE (C-EMB-PURPE) PINK (C-EMB-PINK) BUE (C-EMB-BUE) GREEN (C-EMB-GREEN) SIVER (C-EMB-SIVER) WOR ONE WOR TWO Helvetica (C-EMB-HEVETICA) Garamond (C-EMB-GARAMON) (C-EMB-TWIIGHT) (C-EMB-SCRIPT) 5 (C-A--WING-5-IN) 6 (C-A--WING-6-IN) 8 (C-A--WING-8-IN) 5 (C-WING-5-IN) 6 (C-WING-6-IN) 8 (C-WING-8-IN) EXTRA 11 GROWTH KIT Cushion Foam GROWTH KIT INCUES: 2 or 4 growth plate that bolts onto the bottom of existing shell to grow the back support in length. An additional 2 or 4 cushion and cover will be supplied based on selected growth plate. All mounting hardware included in kit. 2 GROWTH PATE With A FOAM & COVER (C-2 GK) $ (C-A-R-WING-5-IN) 6 (C-A-R-WING-6-IN) 8 (C-A-R-WING-8-IN) 2 or 4 Growth Plate 4 GROWTH PATE With A FOAM & COVER (C-4 GK) $ /5

3 12 PRIVACY FAP Privacy Flap PRIVACY FAP (C-PF-CV) $35.00 Privacy Flap connects with hook and loop attachment between the seat and back support for added privacy. 13 STRAP EXTENSION GUIE BRACKET Strap Extension Guide Bracket EXTRA SMA (CHG2-EB1) Up to 1 1/2 wide webbing. SMA (CHG2-EB2) Up to 2 1/4 wide webbing. $61.00 $ BOIINK ATERA TRUNK SUPPORT PA STYE HCPCS Code: E0956 You may make one selection per column (eft, Extra eft, 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. GT3 and GT2 Hardware and Pads are interchangeable BASIC STYE PREMIUM STYE A. SIZE & SHAPE $82.00ea. SHAPE SIZE *EXTRA *EXTRA 3 x 4 B-TSP1S-34-H B-TSP1S-34-RH 3 x 5 B-TSP1S-35-H B-TSP1S-35-RH 4 x 5 B-TSP1S-45-H B-TSP1S-45-RH 4 x 6 B-TSP1S-46-H B-TSP1S-46-RH 5 x 7 B-TSP1S-57-H B-TSP1S-57-RH 6 x 6 B-TSP1S-66-H B-TSP1S-66-RH SUPPORTIVE - OR - - OR - A. SIZE & SHAPE SHAPE $88.00ea. SIZE *EXTRA *EXTRA 3 x 4 B-TSP2S-34-H B-TSP2S-34-RH 3 x 5 B-TSP2S-35-H B-TSP2S-35-RH 4 x 5 B-TSP2S-45-H B-TSP2S-45-RH 4 x 6.5 B-TSP2S-46-H B-TSP2S-46-RH 5 x 6.5 B-TSP2S-56-H B-TSP2S-56-RH 6 x 6.5 B-TSP2S-66-H B-TSP2S-66-RH SUPPORTIVE 3 x 4 B-TSP1A-34-H B-TSP1A-34-RH 3 x 4 B-TSP2A-34-H B-TSP2A-34-RH ACTIVE 3 x 5 B-TSP1A-35-H B-TSP1A-35-RH 4 x 5 B-TSP1A-45-H B-TSP1A-45-RH 4 x 6 B-TSP1A-46-H B-TSP1A-46-RH 5 x 7 B-TSP1A-57-H B-TSP1A-57-RH ACTIVE 3 x 5 B-TSP2A-35-H 4 x 5 B-TSP2A-45-H 4 x 6.5 B-TSP2A-46-H 5 x 6.5 B-TSP2A-56-H B-TSP2A-35-RH B-TSP2A-45-RH B-TSP2A-46-RH B-TSP2A-56-RH 6 x 6 B-TSP1A-66-H B-TSP1A-66-RH 6 x 6.5 B-TSP2A-66-H B-TSP2A-66-RH B. STYE STYE *EXTRA *EXTRA B. STYE STYE *EXTRA *EXTRA MOABE TS-P1-MO TS-P1-MO MOABE TS-P2-MO TS-P2-MO RIGI TS-P1-RIGI TS-P1-RIGI RIGI TS-P2-RIGI TS-P2-RIGI C. COVER COVER *EXTRA *EXTRA C. COVER COVER *EXTRA *EXTRA COMFORT-TEK TS-P1-COMFORT TS-P1-COMFORT STRETCH-AIR TS-P1-STRETCH TS-P1-STRETCH NO COVER $0 TS-P2-NO-CV TS-P2-NO-CV COMFORT-TEK $0 TS-P2-COMFORT TS-P2-COMFORT STRETCH-AIR $0 TS-P2-STRETCH TS-P2-STRETCH * EXTRA parts may not fit depending on back support, pad, and hardware size and style combinations (especially back supports 16 or less). Please contact customer support with questions BOIINK TS HARWARE GIEWEAR $13.00ea. TS-P2-GIE TS-P2-GIE COMFORT-TEK w/ FOAM $13.00ea. TS-P2-COMFORT-FM TS-P2-COMFORT-FM STRETCH-AIR w/ FOAM $13.00ea. TS-P2-STRETCH-FM TS-P2-STRETCH-FM GIEWEAR w/ FOAM $26.00ea. TS-P2-GIE-FM TS-P2-GIE-FM * EXTRA parts may not fit depending on back support, pad, and hardware size and style combinations. GT FIXE Open Position FIXE SOT MOUNT $271.00ea. SOT MOUNT w/ $425.00ea. **EXTRA **EXTRA **EXTRA **EXTRA B-TS-GT1SAS-H B-TS-GT1SAS-H B-TS-GT1SAS-RH B-TS-GT1SAS-RH B-TS-GT1SAWSAE-H B-TS-GT1SAWSAE-H B-TS-GT1SAWSAE-RH B-TS-GT1SAWSAE-RH SOT MOUNT $129.00ea. SOT MOUNT w/ $283.00ea. **EXTRA **EXTRA **EXTRA **EXTRA B-TS-GT1FXS-H B-TS-GT1FXS-H B-TS-GT1FXS-RH B-TS-GT1FXS-RH B-TS-GT1FXWSAE-H B-TS-GT1FXWSAE-H B-TS-GT1FXWSAE-RH B-TS-GT1FXWSAE-RH GT2 FIXE Open Position FIXE SOT MOUNT $298.00ea. SOT MOUNT w/ $452.00ea. **EXTRA **EXTRA **EXTRA **EXTRA B-TS-GT2SAS-H B-TS-GT2SAS-H B-TS-GT2SAS-RH B-TS-GT2SAS-RH B-TS-GT2SAWSAE-H B-TS-GT2SAWSAE-H B-TS-GT2SAWSAE-RH B-TS-GT2SAWSAE-RH SOT MOUNT $178.00ea. SOT MOUNT w/ $332.00ea. **EXTRA **EXTRA **EXTRA **EXTRA B-TS-GT2FXS-H B-TS-GT2FXS-H B-TS-GT2FXS-RH B-TS-GT2FXS-RH B-TS-GT2FXWSAE-H B-TS-GT2FXWSAE-H B-TS-GT2FXWSAE-RH B-TS-GT2FXWSAE-RH 3/5

4 16 AITIONA TS HARWARE Extra links and long mounting bracket will only work with their designated hardware style. GT EXTRA HARWARE INKS 1 HARWARE COVER GT2 $26.00ea. HARWARE** $154.00ea. AITIONA AITIONA EXTRA EXTRA EXTRA EXTRA B-TS-GT1INK B-TS-GT1INK B-TS-GT1INK B-TS-GT1INK B-TS-HWSAE-H B-TS-HWSAE-H B-TS-HWSAE-RH B-TS-HWSAE-RH **Extra Contoured Wing needed (Section 7) to mount extra Winter/Summer hardware. EXTRA HARWARE INKS 1¼ ONG MOUNTING BRACKET adds 1 of adjustment per bracket HARWARE COVER $26.00ea. HARWARE** $154.00ea. AITIONA AITIONA EXTRA EXTRA EXTRA EXTRA EXTRA EXTRA B-TS-GT2INK B-TS-GT2INK B-TS-GT2INK B-TS-GT2INK B-TS-GT2SOT-H B-TS-GT2SOT-H B-TS-GT2SOT-RH B-TS-GT2SOT-RH B-TS-HWSAE-H B-TS-HWSAE-H B-TS-HWSAE-RH B-TS-HWSAE-RH **Extra Contoured Wing needed (Section 7) to mount extra Winter/Summer hardware. 17 BOIINK HEA SUPPORT PA HCPCS Code: E0955 Make a selection in sections A -or- B. *ength () refers to the actual size dimension of the support from bottom to top edge. A. PREMIUM PA SIZE 6Wx3 8W x 4 10W x 5 12W x 5 14W x 5 18W x 5 W A1. PREMIUM PA COVER MATERIA GlideWear provides skin protection and GIEWEAR shear reduction. Not fluid resistant. GIEWEAR (A $26.00) Comfort-Tek provides fluid protection and is an easily cleaned surface. Stretch-Air provides air transmission and heat dissipation. B. BASIC PA SIZE 6Wx5 COMFORT-TEK STRETCH-AIR B-HSP3-6W3 $237.00/EA $129.00/EA 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 COMFORT-TEK STRETCH-AIR 8W x 5 B-HSP3-8W5 10W x 6 B-HSP3-10W6 12W x 6 B-HSP3-12W6 14W x 6 B-HSP3-14W6 14W x 6 B-HSP3-18W6 W B1. BASIC PA COVER MATERIA Comfort-Tek provides fluid protection and is an easily cleaned surface. Stretch-Air provides air transmission and heat dissipation. COMFORT-TEK STRETCH-AIR COMFORT-TEK STRETCH-AIR 4/5

5 18 BOIINK HEA SUPPORT HARWARE Make a selection in sections A -or- B. 19 BOIINK HEA SUPPORT MOUNTING OPTION A. PT HARWARE, REMOVABE POSTERIOR A MOUNTING BOCK HS-MB-POSTA PT HARWARE, MAX 8 PT HARWARE, MI 6 PT HARWARE, AT 6 PT HARWARE, MI 8 PT HARWARE, AT 8 MOUNTING BOCK- POSTERIOR A 20 EXTRA HARWARE STANAR PT STEM, 7 SHAPE MI 6 $ B-HS-PT1RMMI6 AT 6 $ B-HS-PT1RMAT6 MI 8 $ B-HS-PT1RMMI8 AT 8 $ B-HS-PT1RMAT8 MAX 8 $ B-HS-PT1RMMAX8 A1. PT HARWARE STEM ENGTH OPTION PT STEM, 3 ENGTH B. GT HARWARE, REMOVABE STANAR 7 STEM HS-STEM-7 *3 STEM HS-STEM-3 * 3 Stem is recommended for use with power mounting where there may be special constraints with power chair functions 2 INK 3 INK 4 INK TOO-ESS 1/4 SPACER PATE WING OCK *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 $21.00/each B-HS-52WINGA1 B-HS-52WINGA1 B-HS-52WINGA1 B-HS-52WINGA1 1/4 SPACER PATE $37.00 B-HS-SPCRA *PT Hardware Only GT HARWARE, ATERA GT HARWARE, MI-INE SHAPE ATERA $ B-HS-GT3RMAT MI-INE $ B-HS-GT3RMMI NOTES SUBMIT BY EMAI 5/5