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 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 or print and fax to Customer Service at customerservice@comfortcompany.com or 1.406.522.8563. 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 BY SIZE Sizes available with 2 POINT Mounting Hardware ENGTH* $594.00 $673.00 $523.00 $614.00 24 ENGTH* 1622 1822 2022 2222 1420 1620 1820 2020 2220 1218 1418 1618 1818 2018 2218 1216 1416 1616 1816 2016 2216 1214 1414 1614 1814 2014 1212 1412 1612 1812 1210 1410 1610 1810 24 Sizes available are subject to hardware being used. AB-BS Please fill in the above with dimensions from the size charts to the right. Example Part: AB-BS1416 Hardware will be selected in Section 2. IF ESIRE SIZE IS NOT ISTE, PEASE CONTACT CUSTOMER SERVICE F ASSISTANCE. 800.564.9248 ENGTH* Sizes available with 4 POINT Mounting Hardware 1622 1822 2022 2222 2422 1420 1620 1820 2020 2220 2420 1218 1418 1618 1818 2018 2218 2418 1216 1416 1616 1816 2016 2216 1214 1414 1614 1814 2014 1212 1412 1612 1812 1210 1410 1610 1810 24 ENGTH* Sizes available with POER Mounting Hardware 1622 1822 2022 2222 2422 1420 1620 1820 2020 2220 2420 1418 1618 1818 2018 2218 2418 1416 1616 1816 2016 2216 1214 1414 1614 1814 2014 1212 1412 1612 1812 24 ACTA-BACK-ER REV0318 ACTA-BACK ER FM Patient Reference: PAGE 1 of 7
COVER & HARARE 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. COMFT-TEK is a smooth, easily cleaned surface. The fluid protection aids in infection control. COMFT-TEK Cover (COMFT-TEK) STRETCH-AIR has comfortable stretch, air transmission and heat dissipation. It is not fluid resistant. STRETCH-AIR Cover (STRETCH-AIR) 2.2 HARARE STYE COMPASS 4 QUICK REEASE COMPASS 4 FIXE COMPASS POER MOUNT Price included in back support purchase Price included in back support purchase MSRP add $40.00 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 FIXE fully adjustable hardware requires tools for back support removal FIXE 2 POINT (NQ-COMPASS) FIXE 4 POINT (NQ-COMPASS4) POER MOUNT hardware has 8 of height adjustment in ½ increments without using tools. QUANTUM w/ TRU BAANCE 3 (PMB-QUANTUM) PERMOBI w/ CPUS 3G (PMB-PERMOBI) QUICKIE w/ 3.7 POER (PMB-QUICKIE) AVI REHAB w/ POER T & R (PMB-AVI) ROVI w/ MOTION CONCEPTS* (PMB-ROVI) *Using Power Mount Hardware on ROVI requires mounting to the RECESSE PANAR INTERFACE PATE available when ordering the Motion Concepts Seating System. rilling is required for mounting. ACTA-BACK-ER REV0318 ACTA-BACK ER FM Patient Reference: PAGE 2 of 7
BACK SUPPT A-ON SEECTIONS 3 Optional 3.1 CO 3.2 EMBROIERY 3.3 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. THREA CO OPTIONS RE (EMB-RE) BUE (EMB-BUE) PURPE (EMB-PURPE) GREEN (EMB-GREEN) This flap connects with hook & loop attachment between the seat and back for added privacy. PINK (EMB-PINK) SIVER (EMB-SIVER) Color ocation B. FONT OPTIONS Helvetica (EMB-Helvetica) (EMB-Twilight) Garamond (EMB-Garamond) (EMB-Script) RE (RE) PURPE (PURPE) PINK (PINK) BUE (BUE) GREEN (GREEN) ANGE (ANGE) REMOVE (REMOVE) C. ONE TO (optional) *AITIONA EA TIMES MAY APPY PRIVACY FAP (PV-FAP) Privacy Flap 4 BOIINK ATERA TRUNK SUPPT & HARARE 4.1 BASIC PA 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 (next page) 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 SUPPTIVE 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 4.2 Contact Customer Support for custom sizes. 1.800.564.9248. BASIC PA STYE MSRP $0.00/ea. 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 Continue on next page for cover selection (section 4.3) if basic style pads are selected. * EXTRA parts may not fit depending on back support, pad, and hardware size and style combinations. Please contact customer support with questions. ACTA-BACK-ER REV0318 ACTA-BACK ER FM Patient Reference: PAGE 3 of 7
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 $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. 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 $13.00/ea. TS-P2-GIE TS-P2-GIE TS-P2-GIE TS-P2-GIE 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 GIEEAR with FOAM $26.00/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. ACTA-BACK-ER REV0318 ACTA-BACK ER FM Patient Reference: PAGE 4 of 7
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. SING-AAY 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. SOT MOUNTING MSRP EFT *EXTRA EFT RIGHT *EXTRA RIGHT SING-AAY HCPCS Code: E1028 $271.00/ea. B-TS-GT1SAS-H B-TS-GT1SAS-H B-TS-GT1SAS-RH B-TS-GT1SAS-RH FIXE $129.00/ea. B-TS-GT1FXS-H B-TS-GT1FXS-H B-TS-GT1FXS-RH B-TS-GT1FXS-RH 4.8 GT AITIONA OPTIONS 1 EXTRA HARARE INKS EFT A EFT RIGHT A RIGHT MSRP $37.00/link B-TS-GT1INK B-TS-GT1INK B-TS-GT1INK B-TS-GT1INK HARARE 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 HARARE Both Fixed and Swing-Away hardware styles are adjustable. SOT MOUNT Swing-Away Shown Release Button 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 SING-AAY HCPCS Code: E1028 $298.00/ea. B-TS-GT2SAS-H B-TS-GT2SAS-H B-TS-GT2SAS-RH B-TS-GT2SAS-RH FIXE $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 SING-AAY $298.00/ea. B-TS-GT2SAT-H B-TS-GT2SATX-H B-TS-GT2SAT-RH B-TS-GT2SATX-RH HCPCS Code: E1028 FIXE $178.00/ea. B-TS-GT2FXT-H B-TS-GT2FXTX-H B-TS-GT2FXT-RH B-TS-GT2FXTX-RH 4.10 GT2 AITIONA OPTIONS 1¼ adds 1 of adjustment per bracket EXTRA HARARE INKS EFT A EFT RIGHT A 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 For Slot Mount MSRP $37.00/ea B-TS-GT2SOT-H B-TS-GT2SOT-H B-TS-GT2SOT-RH B-TS-GT2SOT-RH ACTA-BACK-ER REV0318 HARARE COVER EFT *EXTRA EFT RIGHT *EXTRA RIGHT MSRP $26.00/ea B-TS-HCOVER B-TS-HCOVER B-TS-HCOVER B-TS-HCOVER ACTA-BACK ER FM Patient Reference: PAGE 5 of 7
5.1 5 BOIINK HEA SUPPT HARARE & PAS PREMIUM PA SIZE HCPCS COING: E0955 MSRP $237.00 6 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- 5.4. 5.2 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 $26.00) Comfort-Tek (COMFT-TEK) Stretch-Air (STRETCH-AIR) 5.3 BASIC PA SIZE HCPCS COING: E0955 MSRP $129.00 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) 5.5 A. PT HARARE, MI 6 14 x 6 18 x 6 B-HSP3-146 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 $223.00 (B-HS-PT1RMMI6) AT 6 $260.00 (B-HS-PT1RMAT6) MI 8 $223.00 (B-HS-PT1RMMI8) AT 8 $260.00 (B-HS-PT1RMAT8) MAX 8* $327.00 (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 6 2 6 5.5 1 N/A AT 6 3 6 5.5 1 6 MI 8 2 8 7.5 1 N/A AT 8 3 8 7.5 1 8 MAX 8 4 8 7.5 3 8 ACTA-BACK-ER REV0318 ACTA-BACK ER FM Patient Reference: PAGE 6 of 7
PT HARARE, REMOVABE (CONTINUE) PT HARARE, STEM ENGTH OPTION STANAR PT STEM, 7 PT STEM, 3 STEM ENGTH MSRP PART NUMBER STANAR 7 STEM $0.00 (HS-STEM-7) **3 Stem is recommended for use with power mounting where there may be special constraints with power chair functions **3 STEM $0.00 (HS-STEM-3) B. GT HARARE, REMOVABE GT HARARE, ATERA GT HARARE, MI-INE GT HARARE RANGE OF MOTION GT MOE TOTA # OF INKS TOTA INK ENGTH ANTERI SIZE & SHAPE MSRP PART NUMBER ATERA $228.00 (B-HS-GT3RMAT) MI-INE $191.00 (B-HS-GT3RMMI) POSTERI ATERA AT 5 10.5 2 7.5 MI 3 8.5 8 2 N/A ACTA-BACK-ER REV0318 5.6 HEA SUPPT MOUNTING OPTION MOUNTING BOCK BRACKET MSRP PART NUMBER MOUNTING BOCK- POSTERI A POSTERI A MOUNTING BOCK $0.00 (HS-MB-POSTA) 5.7 EXTRA HARARE 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) AITIONA MSRP EXTRA PART 1/4 SPACER PATE $37.00/each (B-HS-SPCRA) *F PT HARARE ONY SUBMIT BY EMAI ACTA-BACK ER FM Patient Reference: PAGE 7 of 7