2 Required RADIUS BACK ORDER FORM RB-BS. SIZE SELECTION Required COVER & HARDWARE SELECTION COVER SELECTION MSRP $0.00 HARDWARE SELECTION MSRP $0.

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Jonah Dickerson
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RAIUS BACK ER FM HCPCS COING: E2611/E2612 GENERA USE BACK Company Name/ACCT #: P.O. Number: Requested By: Phone: Email: Ship To: Patient Reference: Fax: For best results, do not fill out in your browser.

Shown with Compass 4 Quick Release 2 Point Hardware. 1 SIZE SEECTION Required BASE MSRP BY SIZE *ength () refers to the actual size dimension of the support from bottom to top edge.

00 ENGTH* 20 18 1620 1820 2020 2220 1618 1818 2018 2218 2420 2418 16 16 1616 1816 2016 2216 16 18 20 22 24 RB-BS FRAME ITH Sizes available are subject to hardware being used.

564.9248 COVER & HARARE SEECTION 2 Required 2.1 COVER SEECTION MSRP $0.00 2.2 HARARE SEECTION MSRP $0.00 Both fabrics are latex-free. Fabric selection is for the support surface only.

1 RAIUS BACK ER FM HCPCS COING: E2611/E2612 GENERA USE BACK 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. 1 SIZE SEECTION Required BASE MSRP BY SIZE *ength () refers to the actual size dimension of the support from bottom to top edge. 2 POINT Mounting Hardware Only 4 POINT Only ENGTH* $ $ ENGTH* RB-BS FRAME ITH Sizes available are subject to hardware being used. Please fill in the above with dimensions from the size chart to the right. Example Part: RB-BS FRAME ITH IF ESIRE SIZE IS NOT ISTE, PEASE CONTACT CUSTOMER SERVICE F ASSISTANCE COVER & HARARE SEECTION 2 Required 2.1 COVER SEECTION MSRP $ HARARE 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. COMFT-TEK is a smooth, easily cleaned surface. The fluid protection aids in infection control. STRETCH-AIR has comfortable stretch, air transmission and heat dissipation. It is not fluid resistant. F COMPASS 4 QUICK REEASE F 24 4 POINT TOP VIE RAIUS-BACK-ER REV0218 COMFT-TEK Cover (COMFT-TEK) STRETCH-AIR Cover (STRETCH-AIR) QUICK REEASE 2 POINT (Q-COMPASS) QUICK REEASE 4 POINT (Q-COMPASS4) RAIUS BACK ER FM Patient Reference: PAGE 1 of 6

BACK SUPPT A-ON SEECTIONS 3 Optional 3.1 UMBAR SUPPT 3.2 EMBROIERY MSRP $34.00 MSRP $25.00 Height adjustable lumbar support. A. THREA CO OPTIONS RE (EMB-RE) BUE (EMB-BUE) PURPE (EMB-PURPE) PINK (EMB-PINK) GREEN (EMB-GREEN) SIVER (EMB-SIVER) B.

2 BACK SUPPT A-ON SEECTIONS 3 Optional 3.1 UMBAR SUPPT 3.2 EMBROIERY MSRP $34.00 MSRP $25.00 Height adjustable lumbar support. A. THREA CO OPTIONS RE (EMB-RE) BUE (EMB-BUE) PURPE (EMB-PURPE) PINK (EMB-PINK) GREEN (EMB-GREEN) SIVER (EMB-SIVER) B. FONT OPTIONS Helvetica (EMB-Helvetica) (EMB-Twilight) Garamond (EMB-Garamond) (EMB-Script) 16 (BK-RUMBAR-16) 18 (BK-RUMBAR-18) 20 (BK-RUMBAR-20) C. ONE TO (optional) 22 (BK-RUMBAR-22) *AITIONA EA TIMES MAY APPY BOIINK ATERA TRUNK SUPPT & HARARE BASIC PA SIZE & SHAPE HCPCS Code: E0956 MSRP $79.00/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. *ength () refers to the actual size dimension of the support from top to bottom edge. epth () refers to the actual size dimension from anterior to posterior edge. SHAPE SIZE EFT *EXTRA EFT RIGHT *EXTRA RIGHT 4.2 SUPPTIVE Contact Customer Support for custom sizes BASIC PA STYE MSRP $0.00/ea. SUPPTIVE 3 x 4 B-TSP1S-34-H B-TSP1S-34-H B-TSP1S-34-RH B-TSP1S-34-RH 3 x 5 B-TSP1S-35-H B-TSP1S-35-H B-TSP1S-35-RH B-TSP1S-35-RH 4 x 5 B-TSP1S-45-H B-TSP1S-45-H B-TSP1S-45-RH B-TSP1S-45-RH 4 x 6 B-TSP1S-46-H B-TSP1S-46-H B-TSP1S-46-RH B-TSP1S-46-RH 5 x 7 B-TSP1S-57-H B-TSP1S-57-H B-TSP1S-57-RH B-TSP1S-57-RH 6 x 6 B-TSP1S-66-H B-TSP1S-66-H B-TSP1S-66-RH B-TSP1S-66-RH 3 x 4 B-TSP1A-34-H B-TSP1A-34-H B-TSP1A-34-RH B-TSP1A-34-RH 3 x 5 B-TSP1A-35-H B-TSP1A-35-H B-TSP1A-35-RH B-TSP1A-35-RH 4 x 5 B-TSP1A-45-H B-TSP1A-45-H B-TSP1A-45-RH B-TSP1A-45-RH 4 x 6 B-TSP1A-46-H B-TSP1A-46-H B-TSP1A-46-RH B-TSP1A-46-RH 5 x 7 B-TSP1A-57-H B-TSP1A-57-H B-TSP1A-57-RH B-TSP1A-57-RH 6 x 6 B-TSP1A-66-H B-TSP1A-66-H B-TSP1A-66-RH B-TSP1A-66-RH MOABE STYE OPTIONS EFT *EXTRA EFT RIGHT *EXTRA RIGHT MOABE TS-P1-MO TS-P1-MO TS-P1-MO TS-P1-MO RIGI TS-P1-RIGI TS-P1-RIGI TS-P1-RIGI TS-P1-RIGI RIGI * EXTRA parts may not fit depending on back support, pad, and hardware size and style combinations. Please contact customer support with questions. RAIUS-BACK-ER REV0218 RAIUS BACK ER FM Patient Reference: PAGE 2 of 6

3 4.3 BASIC PA COVER MSRP $0.00/ea. COMFT-TEK F FUI PROTECTION & AN EASIY CEANE SURFACE. STRETCH-AIR F AIR TRANSMISSION & HEAT ISSIPATION. 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 4.4 PREMIUM PA SIZE & SHAPE HCPCS Code: E0956 MSRP $84.83/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. epth () refers to the dimension of the support from anterior to posterior edge. SHAPE SIZE EFT *EXTRA EFT RIGHT *EXTRA RIGHT 3 x 4 B-TSP2S-34-H B-TSP2S-34-H B-TSP2S-34-RH B-TSP2S-34-RH SUPPTIVE SUPPTIVE 3 x 5.5 B-TSP2S-35-H B-TSP2S-35-H B-TSP2S-35-RH B-TSP2S-35-RH 4 x 5 B-TSP2S-45-H B-TSP2S-45-H B-TSP2S-45-RH B-TSP2S-45-RH 4 x 6.5 B-TSP2S-46-H B-TSP2S-46-H B-TSP2S-46-RH B-TSP2S-46-RH 5 x 6.5 B-TSP2S-56-H B-TSP2S-56-H B-TSP2S-56-RH B-TSP2S-56-RH 6 x 6.5 B-TSP2S-66-H B-TSP2S-66-H B-TSP2S-66-RH B-TSP2S-66-RH 3 x 4 B-TSP2A-34-H B-TSP2A-34-H B-TSP2A-34-RH B-TSP2A-34-RH 3 x 5.5 B-TSP2A-35-H B-TSP2A-35-H B-TSP2A-35-RH B-TSP2A-35-RH 4 x 5 B-TSP2A-45-H B-TSP2A-45-H B-TSP2A-45-RH B-TSP2A-45-RH 4 x 6.5 B-TSP2A-46-H B-TSP2A-46-H B-TSP2A-46-RH B-TSP2A-46-RH 5 x 6.5 B-TSP2A-56-H B-TSP2A-56-H B-TSP2A-56-RH B-TSP2A-56-RH 6 x 6.5 B-TSP2A-66-H B-TSP2A-66-H B-TSP2A-66-RH B-TSP2A-66-RH 4.5 PREMIUM PA STYE MSRP $0.00/ea. MOABE RIGI * 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 MOABE TS-P2-MO TS-P2-MO TS-P2-MO TS-P2-MO RIGI TS-P2-RIGI TS-P2-RIGI TS-P2-RIGI TS-P2-RIGI 4.6 PREMIUM PA 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 GIEEAR $12.44/ea. TS-P2-GIE TS-P2-GIE TS-P2-GIE TS-P2-GIE COMFT-TEK with FOAM $12.44/ea. TS-P2-COMFT-FM TS-P2-COMFT-FM TS-P2-COMFT-FM TS-P2-COMFT-FM STRETCH-AIR with FOAM $12.44/ea. TS-P2-STRETCH-FM TS-P2-STRETCH-FM TS-P2-STRETCH-FM TS-P2-STRETCH-FM GIEEAR with FOAM $24.88/ea. TS-P2-GIE-FM TS-P2-GIE-FM TS-P2-GIE-FM TS-P2-GIE-FM COMFT-TEK F FUI PROTECTION & AN EASIY CEANE SURFACE. STRETCH-AIR F AIR TRANSMISSION & HEAT ISSIPATION. F SKIN PROTECTION & SHEAR REUCTION. NOT FUI RESISTANT. COVER with FOAM F SOFT FEE, NON-ZERO CUSHIONING SUPPT. RAIUS-BACK-ER REV0218 RAIUS BACK ER FM Patient Reference: PAGE 3 of 6

4.7 GT MOUNTING HARARE * EXTRA parts may not fit depending on back support, pad,

Both Fixed and Swing-Away hardware styles are adjustable.

eft, Right, and Extra Right) in section 4.7.

GT hardware extra links (section 4.8) will only work with GT style hardware.

B-TS-GT1SAC-H B-TS-GT1SAC-H B-TS-GT1SAC-RH B-TS-GT1SAC-RH FIXE $150.00/ea.

8 GT AITIONA OPTIONS 1 EXTRA HARARE INKS EFT A EFT RIGHT A RIGHT MSRP $35.

RIGHT EXTRA RIGHT MSRP $24.88/ea B-TS-HCOVER B-TS-HCOVER B-TS-HCOVER B-TS-HCOVER 4.

10) will only work with GT2 style hardware.

B-TS-GT2FXC-H B-TS-GT2FXC-H B-TS-GT2FXC-RH B-TS-GT2FXC-RH 4.

4 4.7 GT MOUNTING HARARE * 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. FIXE Release Button Open Position 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. CANE MOUNTING MSRP EFT *EXTRA EFT RIGHT *EXTRA RIGHT HCPCS Code: E1028 $263.00/ea. B-TS-GT1SAC-H B-TS-GT1SAC-H B-TS-GT1SAC-RH B-TS-GT1SAC-RH FIXE $150.00/ea. B-TS-GT1FXC-H B-TS-GT1FXC-H B-TS-GT1FXC-RH B-TS-GT1FXC-RH 4.8 GT AITIONA OPTIONS 1 EXTRA HARARE INKS EFT A EFT RIGHT A RIGHT MSRP $35.00/link B-TS-GT1INK B-TS-GT1INK B-TS-GT1INK B-TS-GT1INK HARARE COVER EFT *EXTRA EFT RIGHT EXTRA RIGHT MSRP $24.88/ea B-TS-HCOVER B-TS-HCOVER B-TS-HCOVER B-TS-HCOVER 4.9 GT2 MOUNTING HARARE Both Fixed and Swing-Away hardware styles are adjustable. FIXE You may make one selection per column in section 4.9. GT2 hardware extra links (section 4.10) will only work with GT2 style hardware. Release Button Open Position CANE MOUNTING MSRP EFT *EXTRA EFT RIGHT *EXTRA RIGHT HCPCS Code: E1028 $289.30/ea. B-TS-GT2SAC-H B-TS-GT2SAC-H B-TS-GT2SAC-RH B-TS-GT2SAC-RH FIXE $184.83/ea. B-TS-GT2FXC-H B-TS-GT2FXC-H B-TS-GT2FXC-RH B-TS-GT2FXC-RH 4.10 GT2 AITIONA OPTIONS 1¼ EXTRA HARARE INKS EFT A EFT RIGHT A RIGHT MSRP $35.00/link B-TS-GT2INK B-TS-GT2INK B-TS-GT2INK B-TS-GT2INK HARARE COVER EFT *EXTRA EFT RIGHT *EXTRA RIGHT MSRP $24.88/ea B-TS-HCOVER B-TS-HCOVER B-TS-HCOVER B-TS-HCOVER RAIUS-BACK-ER REV0218 RAIUS BACK ER FM Patient Reference: PAGE 4 of 6

5.1 5 BOIINK HEA SUPPT HARARE & PAS PREMIUM PA SIZE HCPCS COING: E0955 MSRP $230.

Head Support Pads angles can be formed by adjusting the plates in the pad. You may make one selection per column.

cover Head material Support Pad in 5.2 Pictured -or- 5.4. 5.2 PREMIUM PA COVER MATERIA COMFT-TEK F FUI PROTECTION & AN EASIY CEANE SURFACE.

00) Comfort-Tek (COMFT-TEK) Stretch-Air (STRETCH-AIR) 5.3 BASIC PA SIZE HCPCS COING: E0955 MSRP $125.

4 BASIC PA COVER MATERIA 6 x 5 B-HSP3-65 COMFT-TEK F FUI PROTECTION & AN EASIY CEANE SURFACE.

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.

PT HARARE, MI 6 18 x 6 B-HSP3-186 HEA SUPPT HARARE HCPCS COING: E1028 PT HARARE, REMOVABE PT HARARE, AT 6 PT HARARE, MI 8 SIZE & SHAPE

5 5.1 5 BOIINK HEA SUPPT HARARE & PAS PREMIUM PA SIZE HCPCS COING: E0955 MSRP $ x 3 8 x 4 10 x 5 12 x 5 14 x 5 18 x 5 Pad Firmness Extra Extra Extra Extra Extra Extra ength () refers to the actual size dimension of the support from bottom to top edge. B-HSP1-63 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 PA COVER MATERIA COMFT-TEK F FUI PROTECTION & AN EASIY CEANE SURFACE. STRETCH-AIR F SKIN PROTECTION & SHEAR REUCTION. NOT FUI RESISTANT. F AIR TRANSMISSION & HEAT ISSIPATION. Glideear (GIEEAR) (add $25.00) Comfort-Tek (COMFT-TEK) Stretch-Air (STRETCH-AIR) 5.3 BASIC PA SIZE HCPCS COING: E0955 MSRP $ ength () refers to the actual size dimension of the support from bottom to top edge. 5.4 BASIC PA COVER MATERIA 6 x 5 B-HSP3-65 COMFT-TEK F FUI PROTECTION & AN EASIY CEANE SURFACE. 8 x 5 B-HSP3-85 STRETCH-AIR F AIR TRANSMISSION & HEAT ISSIPATION. 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 (COMFT-TEK) Stretch-Air (STRETCH-AIR) 14 x 6 B-HSP A. PT HARARE, MI 6 18 x 6 B-HSP3-186 HEA SUPPT HARARE HCPCS COING: E1028 PT HARARE, REMOVABE PT HARARE, AT 6 PT HARARE, MI 8 SIZE & SHAPE MSRP PART NUMBER 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) PT HARARE, 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 HARARE, MAX 8 *Provides the greatest amount of articulation and range of motion. PT HARARE RANGE OF MOTION PT MOE TOTA # OF INKS TOTA INK ENGTH ANTERI POSTERI ATERA MI N/A AT MI N/A AT MAX RAIUS-BACK-ER REV0218 RAIUS BACK ER FM Patient Reference: PAGE 5 of 6

PT HARARE, REMOVABE (CONTINUE) PT HARARE, STEM ENGTH OPTION

6 STEM ENGTH MSRP PART NUMBER STANAR 7 STEM $0.

00 (HS-STEM-3) GT HARARE, REMOVABE GT HARARE, ATERA GT HARARE,

with power mounting where there may be special constraints with

INKS TOTA INK ENGTH ANTERI SIZE & SHAPE MSRP PART NUMBER ATERA

48 (B-HS-GT3RMMI) POSTERI ATERA AT 5 10.5 10 2 7.5 MI 3 8.

POSTERI B POSTERI B MOUNTING BOCK $0.00 (HS-MB-POSTB) 5.

73 (B-HS-PT1INK4) TOO-ESS ING OCK MSRP EXTRA PART EXTRA PART

6 PT HARARE, REMOVABE (CONTINUE) PT HARARE, STEM ENGTH OPTION STANAR PT STEM, 7 PT STEM, 3 B. 5.6 STEM ENGTH MSRP PART NUMBER STANAR 7 STEM $0.00 (HS-STEM-7) **3 STEM $0.00 (HS-STEM-3) GT HARARE, REMOVABE GT HARARE, ATERA GT HARARE, MI-INE HEA SUPPT MOUNTING OPTION **3 Stem is recommended for use with power mounting where there may be special constraints with power chair functions GT HARARE RANGE OF MOTION GT MOE TOTA # OF INKS TOTA INK ENGTH ANTERI SIZE & SHAPE MSRP PART NUMBER ATERA $ (B-HS-GT3RMAT) MI-INE $ (B-HS-GT3RMMI) POSTERI ATERA AT MI N/A MOUNTING BOCK BRACKET MSRP PART NUMBER MOUNTING BOCK- POSTERI B POSTERI B MOUNTING BOCK $0.00 (HS-MB-POSTB) 5.7 EXTRA HARARE INK ENGTH MSRP EXTRA PART *EXTRA 2 INK $54.73 (B-HS-PT1INK2) *EXTRA 3 INK $54.73 (B-HS-PT1INK3) *EXTRA 4 INK $54.73 (B-HS-PT1INK4) TOO-ESS ING OCK MSRP EXTRA PART EXTRA PART EXTRA PART EXTRA PART *1 OCK $19.90/each (B-HS-52INGA1) (B-HS-52INGA1) (B-HS-52INGA1) (B-HS-52INGA1) AITIONA MSRP EXTRA PART 1/4 SPACER PATE $35.00/each (B-HS-SPCRA) *F PT HARARE ONY RAIUS-BACK-ER REV0218 SUBMIT BY EMAI RAIUS BACK ER FM Patient Reference: PAGE 6 of 6

This back support is also available through. Sizes available with 2 POINT Mounting Hardware

ACTA-BACK ER FM HCPCS COING: E2613/E2614 Company Name/ACCT #: POSITIONING BACK P.O. Number: Requested By: Phone: Fax: Email: This back support is also available through Ship To: Patient Reference: For