ACTA-RELIEF LTS ORDER FORM
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1 ACTA-REIEF TS ORDER FORM HCPCS CODING: E2620 POSITIONING BACK, PANAR ITH ATERA SUPPORTS Acta-Relief Patent Pending 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 or print and fax to Customer Service at or Shown with Compass 4 Quick Release 2 Point Hardware. Cover appearance may vary with hardware selection. 1 SIZE SEECTION Required *ength () refers to the actual size dimension of the support from bottom to top edge. BASE MSRP Sizes available with 2 POINT Mounting Hardware ENGTH* $ ENGTH* Sizes available are subject to hardware being used. ARTS-BS Please fill in one of the above with dimensions from the size charts to the right. Example Part: ARTS-BS1416 Hardware will be selected in Section 2. ENGTH* Sizes available with 4 POINT Mounting Hardware IF DESIRED SIZE IS NOT ISTED, PEASE CONTACT CUSTOMER SERVICE FOR ASSISTANCE ENGTH* Sizes available with POER Mounting Hardware ACTA-REIEF-TS-ORDER REV0518 ACTA-REIEF TS ORDER FORM Patient Reference: PAGE 1 of 5
2 COVER & HARDARE SEECTION 2 Required 2.1 COVER SEECTION MSRP $0.00 Both fabrics are latex-free. Fabric selection is for the support surface only. Other fabrics used in cover construction remain the same. is a smooth, easily cleaned surface. The fluid protection aids in infection control. Cover (COMFORT-TEK) has comfortable stretch, air transmission and heat dissipation. It is not fluid resistant. Cover (STRETCH-AIR) 2.2 HARDARE STYE COMPASS 4 QUICK REEASE COMPASS 4 FIXED COMPASS POER MOUNT Price included in back support purchase Price included in back support purchase MSRP add $40.00 FIXED fully adjustable hardware requires tools for back support removal POER MOUNT hardware has 8 of height adjustment in ½ increments without using tools. QUICK REEASE 2 POINT (Q-COMPASS) QUICK REEASE 4 POINT (Q-COMPASS4) 4 POINT hardware is required on all 24 back supports using Compass 4 hardware. TOP VIE FIXED 2 POINT (NQ-COMPASS) FIXED 4 POINT (NQ-COMPASS4) QUANTUM w/ TRU BAANCE 3 (PMB-QUANTUM) PERMOBI w/ CORPUS 3G (PMB-PERMOBI) QUICKIE w/ 3.7 POER (PMB-QUICKIE) AVID REHAB w/ POER T & R (PMB-AVID) ROVI w/ MOTION CONCEPTS* (PMB-ROVI) *Using Power Mount Hardware on ROVI requires mounting to the RECESSED PANAR INTERFACE PATE available when ordering the Motion Concepts Seating System. Drilling is required for mounting. ACTA-REIEF-TS-ORDER REV0518 ACTA-REIEF TS ORDER FORM Patient Reference: PAGE 2 of 5
3 3.1 3 ATERA TRUNK SUPPORT SEECTION 3.1 Required (3.2 Optional) ATERA TRUNK SUPPORT Price included in back support purchase 3.2 ADDITIONA ATERA TRUNK SUPPORT HARDARE OPTIONS ength () refers to the actual size dimension of the support from top to bottom edge. Depth (D) refers to the actual size dimension of the support from anterior to posterior edge. TS back supports come with moldable stainless steel supports and rigid mounting hardware. Hardware is width and depth adjustable. Height adjustable on back support shell. Adjustments require tools. is a smooth, easily cleaned surface. The fluid protection aids in infection control. has comfortable stretch, air transmission and heat dissipation. MODABE SUPPORT Size D 4 D x 3 5 D x 4 6 D x 4 7 D x 5 Cover Style RIGID HARDARE (AT-4D3-COMFORT-TEK) (AT-4D3-STRETCH-AIR) (AT-5D4-COMFORT-TEK) (AT-5D4-STRETCH-AIR) (AT-6D4-COMFORT-TEK) (AT-6D4-STRETCH-AIR) (AT-7D5-COMFORT-TEK) (AT-7D5-STRETCH-AIR) SING-AAY HARDARE EFT *EXTRA EFT Release Button HCPCS Code: E1028 B-TS-GT1SAK-H B-TS-GT1SAK-H MSRP $271.00/ea. RIGHT *EXTRA RIGHT Open Position B-TS-GT1SAK-RH B-TS-GT1SAK-RH Hardware is width and depth adjustable. Height adjustable on back support shell. Adjustments require tools. * EXTRA parts may not fit depending on back support, pad, and hardware size and style combinations. EXTRA HARDARE INKS EFT ADD EFT 1 MSRP $37.00/link B-TS-GT1INK B-TS-GT1INK RIGHT B-TS-GT1INK HARDARE COVER EFT EXTRA EFT MSRP $27.00/ea B-TS-HCOVER B-TS-HCOVER RIGHT B-TS-HCOVER ADD RIGHT B-TS-GT1INK EXTRA RIGHT B-TS-HCOVER 4 BACK SUPPORT ADD-ON SEECTIONS Optional 4.1 COOR 4.2 EMBROIDERY 4.3 PRIVACY FAP MSRP $26.00 MSRP $26.00 MSRP $37.00 Accent colors are applied via colored piping. Placement of the piping may vary by back support size and mounting hardware. If no colors are selected, our standard silver reflective piping is used at no additional cost. A. THREAD COOR OPTIONS RED (EMB-RED) BUE (EMB-BUE) PURPE (EMB-PURPE) GREEN (EMB-GREEN) PINK (EMB-PINK) SIVER (EMB-SIVER) This flap connects with hook & loop attachment between the seat and back for added privacy. B. FONT OPTIONS Helvetica (EMB-Helvetica) (EMB-Twilight) Color ocation Garamond (EMB-Garamond) (EMB-Script) RED (RED) PURPE (PURPE) PINK (PINK) BUE (BUE) GREEN (GREEN) ORANGE (ORANGE) C. ORD ONE ORD TO (optional) *ADDITIONA EAD TIMES MAY APPY PRIVACY FAP (PV-FAP) Privacy Flap ACTA-REIEF-TS-ORDER REV0518 REMOVE (REMOVE) ACTA-REIEF TS ORDER FORM Patient Reference: PAGE 3 of 5
4 5.1 5 BODIINK HEAD SUPPORT HARDARE & PADS PREMIUM PAD SIZE HCPCS CODING: E0955 MSRP $ x 3 8 x 4 10 x 5 12 x 5 14 x 5 18 x 5 Pad Firmness ength () refers to the actual size dimension of the support from bottom to top edge. B-HSP1-63 B-HSP2-63 B-HSP1-84 B-HSP2-84 B-HSP1-105 B-HSP2-105 B-HSP1-125 B-HSP2-125 B-HSP1-145 B-HSP2-145 B-HSP1-185 B-HSP2-185 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 14 a x 5 cover Head material Support Pad in 5.2 Pictured -or PREMIUM PAD COVER MATERIA COMFORT-TEK FOR FUID PROTECTION & AN EASIY CEANED SURFACE. STRETCH-AIR FOR SKIN PROTECTION & SHEAR REDUCTION. NOT FUID RESISTANT. FOR AIR TRANSMISSION & HEAT DISSIPATION. Glideear (GIDEEAR) (add $26.00) Comfort-Tek (COMFORT-TEK) Stretch-Air (STRETCH-AIR) 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 6 x 5 B-HSP3-65 COMFORT-TEK FOR FUID PROTECTION & AN EASIY CEANED SURFACE. 8 x 5 B-HSP3-85 STRETCH-AIR FOR AIR TRANSMISSION & HEAT DISSIPATION. 10 x 6 12 x 6 B-HSP3-106 B-HSP3-126 Basic head support pads can be formed to any shape using the moldable steel insert inside the pad. Comfort-Tek (COMFORT-TEK) Stretch-Air (STRETCH-AIR) 14 x 6 B-HSP x 6 B-HSP A. PT HARDARE, MID 8 HEAD SUPPORT HARDARE HCPCS CODING: E1028 PT HARDARE, REMOVABE PT HARDARE, AT 8 PT HARDARE, MAX 8 PT HARDARE, MID 6 SIZE & SHAPE MSRP PART NUMBER MID 8 $ (B-HS-PT1RMMID8) AT 8 $ (B-HS-PT1RMAT8) MAX 8* $ (B-HS-PT1RMMAX8) MID 6 $ (B-HS-PT1RMMID6) AT 6 $ (B-HS-PT1RMAT6) PT HARDARE, AT 6 You may make one selection per column in either A -or- B. If choosing 5.5 A, choose a stem length option to the right. Choose which mounting block option you require in 5.6. *Provides the greatest amount of articulation and range of motion. PT HARDARE RANGE OF MOTION PT MODE TOTA # OF INKS TOTA INK ENGTH ANTERIOR POSTERIOR ATERA MID N/A AT MAX MID N/A AT ACTA-REIEF-TS-ORDER REV0518 ACTA-REIEF TS ORDER FORM Patient Reference: PAGE 4 of 5
5 STANDARD PT STEM, 7 PT STEM, 3 PT HARDARE (CONTINUED) PT HARDARE, STEM ENGTH OPTION STEM ENGTH MSRP PART NUMBER STANDARD 7 STEM $0.00 (HS-STEM-7) ***3 STEM $0.00 (HS-STEM-3) ***3 Stem is recommended for use with power mounting where there may be special constraints with power chair functions B. 5.6 GT HARDARE, REMOVABE GT HARDARE, ATERA GT HARDARE, MID-INE HEAD SUPPORT MOUNTING OPTION GT HARDARE RANGE OF MOTION GT MODE TOTA # OF INKS TOTA INK ENGTH ANTERIOR SIZE & SHAPE MSRP PART NUMBER ATERA $ (B-HS-GT3RMAT) MID-INE $ (B-HS-GT3RMMID) POSTERIOR ATERA AT MID N/A MOUNTING BOCK OR BRACKET ITH MOUNTING BOCK MSRP PART NUMBER *ACTA-REIEF 14 BRACKET ITH MOUNTING BOCK $72.00 (HS-MB-AR14) *ACTA-REIEF 16 BRACKET ITH MOUNTING BOCK $72.00 (HS-MB-AR16) BRACKET ITH MOUNTING BOCK- ACTA-REIEF 18 Shown Above For Non-Power Mount Only. MOUNTING BOCK- POSTERIOR A For Acta-Relief with Power Mount Only *ACTA-REIEF 18 BRACKET ITH MOUNTING BOCK $72.00 (HS-MB-AR18) *ACTA-REIEF 20 BRACKET ITH MOUNTING BOCK $72.00 (HS-MB-AR20) POSTERIOR A MOUNTING BOCK $0.00 (HS-MB-POSTA) 5.7 EXTRA HARDARE *For Acta Relief, includes mounting bracket and POSTA block. If you already have an Acta-Relief head support bracket, order POSTA Block 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 ING OCK MSRP EXTRA PART EXTRA PART EXTRA PART EXTRA PART **1 OCK $21.00/each (B-HS-52INGA1) (B-HS-52INGA1) (B-HS-52INGA1) (B-HS-52INGA1) **For PT Hardware Only BRACKET SIZE MSRP PART NUMBER BRACKET- ACTA-REIEF 18 Shown Above *ACTA-REIEF 14 BRACKET $ (B-HS-AR14) *ACTA-REIEF 16 BRACKET $ (B-HS-AR16) *ACTA-REIEF 18 BRACKET $ (B-HS-AR18) *ACTA-REIEF 20 BRACKET $ (B-HS-AR20) *Bracket only, does not include mounting block. ADDITIONA MSRP EXTRA PART 1/4 SPACER PATE $37.00/each (B-HS-SPCRA) ACTA-REIEF-TS-ORDER REV0518 ACTA-REIEF TS ORDER FORM Patient Reference: SUBMIT BY EMAI PAGE 5 of 5
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Quantum R4000 Series Group 3 Single Power & Multiple Power Order Form / ODJSF Only 300 lbs weight capacity
Quantum Rehab A Division of Pride Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA 18643 Phone: (866)800-2002 Fax: (866) 707-3422 Quantum R4000 Series Group 3 Single Power & Multiple Power