CUSTOM ACTA-BACK DEEP ORDER FORM Client Reference: PAGE 1 of 3

*DO NOT SEND PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*

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1 BACK SUPPORT SIZE

C - D - W HHCPCS Code: E2617

2 COVER OPTIONS

4 CUSTOM FOAM SELECTION

REAR LAYER *OPTIONAL*

$0.00H.R. MEDIUM

1/4” (CD-REAR-HRM-0.25)

1/2” (CD-REAR-HRM-0.50)

3/4” (CD-REAR-HRM-0.75) SFC1” (CD-REAR-HRM-1.00)

1 1/4” (CD-REAR-HRM-1.25)

H.R. SOFT

1/4” (CD-REAR-HRS-0.25)

1/2” (CD-REAR-HRS-0.50)

3/4” (CD-REAR-HRS-0.75)

1” (CD-REAR-HRS-1.00)

1 1/4” (CD-REAR-HRS-1.25)

VISCOOL® MEDIUM

1/2” (CD-REAR-VIS-M-0.50)

1” (CD-REAR-VIS-M-1.00)

VISCOOL® SOFT

1/2” (CD-REAR-VIS-S-0.50)

1” (CD-REAR-VIS-S-1.00)

VISCOOL® EXTRA SOFT

1/2” (CD-REAR-VIS-XS-0.50)

1” (CD-REAR-VIS-XS-1.00)

VISCO EXTRA EXTRA SOFT

1/2” (CD-REAR-VIS-XXS-0.50)

1” (CD-REAR-VIS-XXS-1.00)

MIDDLE LAYER *OPTIONAL*

H.R. MEDIUM

1/4” (CD-MID-HRM-0.25)

1/2” (CD-MID-HRM-0.50)

3/4” (CD-MID-HRM-0.75)

1” (CD-MID-HRM-1.00)

1 1/4” (CD-MID-HRM-1.25)

H.R. SOFT

1/4” (CD-MID-HRS-0.25)

1/2” (CD-MID-HRS-0.50)

3/4” (CD-MID-HRS-0.75)

1” (CD-MID-HRS-1.00)

1 1/4” (CD-MID-HRS-1.25)

VISCOOL® MEDIUM

1/2” (CD-MID-VIS-M-0.50)

1” (CD-MID-VIS-M-1.00)

VISCOOL® SOFT

1/2” (CD-MID-VIS-S-0.50)

1” (CD-MID-VIS-S-1.00)

VISCOOL® EXTRA SOFT

1/2” (CD-MID-VIS-XS-0.50)

1” (CD-MID-VIS-XS-1.00)

VISCO EXTRA EXTRA SOFT

1/2” (CD-MID-VIS-XXS-0.50)

1” (CD-MID-VIS-XXS-1.00)

TOPPER LAYER *OPTIONAL*

H.R. MEDIUM

1/4” (CD-TOP-HRM-0.25)

1/2” (CD-TOP-HRM-0.50)

3/4” (CD-TOP-HRM-0.75)

1” (CD-TOP-HRM-1.00)

1 1/4” (CD-TOP-HRM-1.25)

H.R. SOFT

1/4” (CD-TOP-HRS-0.25)

1/2” (CD-TOP-HRS-0.50)

3/4” (CD-TOP-HRS-0.75)

1” (CD-TOP-HRS-1.00)

1 1/4” (CD-TOP-HRS-1.25)

VISCOOL® MEDIUM

1/2” (CD-TOP-VIS-M-0.50)

1” (CD-TOP-VIS-M-1.00)

VISCOOL® SOFT

1/2” (CD-TOP-VIS-S-0.50)

1” (CD-TOP-VIS-S-1.00)

VISCOOL® EXTRA SOFT

1/2” (CD-TOP-VIS-XS-0.50)

1” (CD-TOP-VIS-XS-1.00)

VISCO EXTRA EXTRA SOFT

1/2” (CD-TOP-VIS-XXS-0.50) SFC1” (CD-TOP-VIS-XXS-1.00)

Rear LayerMiddle Layer

Topper Layer

A minimum of one layer must be chosen. A ¼” Crosslink foundation layer comes standard on all back supports.

$0.00

$138.00

$138.00

$138.00

$138.00

$0.00

$0.00

$138.00

$138.00

$138.00

$138.00

$0.00

$0.00

$138.00

$138.00

$138.00

$138.00

12-20” Width / 12-18” Length = $1069.00 Base Price21-24” Width / 12-18” Length = $1175.00 Base Price12-24” Width / 19-22” Length = $1206.00 Base Price25-28” Width / 12-22” Length = $1734.00 Base Price

*If desired size is not listed above, a 60% up charge will be applied for materials.

STRETCH-AIR® W/ DIAMOND $0.00(CD-STRETCH-AIR)

(CD-DIGI-STRETCH-AIR)

COMFORT-TEK® W/ DIAMOND $0.00(CD-COMFORT-TEK)

(CD-DIGI-COMFORT-TEK)

STRETCH-AIR® W/ DIGI-CAMO $0.00

COMFORT-TEK® W/ DIGI-CAMO $0.00

3 MILITARY BRANCH PATCH

AIR FORCE $0.00(CD-AIR-FORCE-PATCH)

ARMY $0.00(CD-ARMY-PATCH)

MARINES $0.00(CD-MARINES-PATCH)

NAVY $0.00(CD-NAVY-PATCH)

*OPTIONAL*

Company Name/ACCT #:

P.O. Number:

Requested By:

Phone: Fax:

Email:

Ship To:

Client Reference:

5 MOLDABLE ALUMINUM STAYSSPACE BETWEEN STAYS $0.00

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.

1” (CD-STAY-1.0)

1 1/2” (CD-STAY-1.5)

2” (CD-STAY-2.0)

2 1/2” (CD-STAY-2.5)

3” (CD-STAY-3.0)

3 1/2” (CD-STAY-3.5)

4” (CD-STAY-4.0)

4 1/2” (CD-STAY-4.5)

SPECIFY CUSTOM SPACING (CD-STAY-OTHER)

NONE (CD-STAY-NONE)

Aluminum Stay Pockets

Moldable Aluminum Stays

Choose either Stretch-Air® or Comfort-Tek® cover fabric with Diamond or Digi-Camo accent fabric. Care for each accent fabric is identical.

NOTE: Desired back support length is “H” dimension in part number above. Cover appearance may vary with hardware selection and size.

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.

SFC = Standard Foam Configuration. Use as a reference when choosing foam layers. =1” (CD-TOP-VIS-XXS-1.00) SFC

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

*DO NOT SEND PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*

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 to orders.comfort@permobil.com or print and fax to 1.406.522.8563.

®*Since U.S. Medicare coding is subject to change, the provider should always confirm the HCPCS code and coverage criteria as part of the client assessment process.*

CUSTOM ACTA-BACK DEEP ORDER FORM Client Reference: PAGE 2 of 3

*DO NOT SEND PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*

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7 COLOR *OPTIONAL*COLOR

Accent colors are applied via colored piping. If no color is selected, our standard silver reflective piping will be used. Placement may vary by hardware being used.

$0.00

RED (CD-RED)

PURPLE (CD-PURPLE)

PINK (CD-PINK)

BLUE (CD-BLUE)

GREEN (CD-GREEN)

ORANGE (CD-ORANGE)

Privacy Flap connects with hook and loop attachment between the seat and back support for added privacy.

$35.00PRIVACY FLAP (CD-PF-CV)

8 PRIVACY FLAP *OPTIONAL*

COLOR LOCATION

$0.00THREAD COLOR OPTIONS

RED (CD-EMB-RED)

PURPLE (CD-EMB-PURPLE)

PINK (CD-EMB-PINK)

BLUE (CD-EMB-BLUE)

GREEN (CD-EMB-GREEN)

SILVER (CD-EMB-SILVER)

FONT STYLE OPTIONSHelvetica (CD-EMB-HELVETICA)

Garamond (CD-EMB-GARAMOND)

(CD-EMB-TWILIGHT)

(CD-EMB-SCRIPT)

WORD ONE

WORD TWO

A. B.9 EMBROIDERY *OPTIONAL*

$0.00

10 SINGLE LATERAL DEPTH$0.00LATERAL DEPTH

OMIT LEFT (CD-DEEP-LAT-L-OMIT)

OMIT RIGHT (CD-DEEP-LAT-R-OMIT)

3” D x 5” L LEFT (CD-DEEP-LAT-L-3)

3” D x 5” L RIGHT (CD-DEEP-LAT-R-3)

5” D x 6” L LEFT (CD-DEEP-LAT-L-5)

5” D x 6” L RIGHT (CD-DEEP-LAT-R-5)

7” D x 7” L LEFT (CD-DEEP-LAT-L-7)

7” D x 7” L RIGHT (CD-DEEP-LAT-R-7)

Laterals are mounted at a fixed height position. Laterals are width and angle adjustable. Lateral pad height changes with different depth selections. If specific wing height location is needed, please indicate in the notes below.

7” 7”5” 5” 7”

22”

9” 11” 12” 13” 13”

7”

14”

18” L Back Support

EXAMPLE

*Length (L) refers to the actual size dimension of the support from bottom to top edge.

6 HARDWARE OPTIONSQuick 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 RELEASE COMPASS® 4 (2 PT)(CD-Q-COMPASS)

FIXED COMPASS® 4 (2 PT)(CD-NQ-COMPASS)

FIXED COMPASS® 4 (4 PT)(CD-NQ-COMPASS4)

QUICK RELEASE COMPASS® 4 (4 PT)(CD-Q-COMPASS4)

COMPASS® 4 BUNDLE(2 PT, 4 PT, QUICK RELEASE & FIXED)(CD-COMPASS-BUNDLE)

$0.00

$0.00

$0.00

$0.00

$481.00

COMPASS® 4 MOUNTING HARDWARECompass® 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”L or 12” W, or sizes 12Wx16L & 12Wx18L*Power Mount Bracket required for all power chairs listed below.

QUANTUM with TRU BALANCE 3

PERMOBIL with CORPUS 3G

QUICKIE with 3.7 POWER

AVID REHAB with POWER T & R

ROVI with MOTION CONCEPTS*

(CD-PMB-QUANTUM)

(CD-PMB-PERMOBIL)

(CD-PMB-QUICKIE)

(CD-PMB-AVID)

(CD-PMB-ROVI)

$515.00

$515.00

$515.00

$515.00

$515.00

*Using Compass® Power Mount on Rovi requires mounting to the RECESSED PLANAR INTERFACE PLATE available when ordering the Motion Concepts Seating System. Drilling is required for mounting.

COMPASS® POWER MOUNT BRACKET

REMOVE (CD-REMOVE)

A1. PREMIUM PAD COVER MATERIAL

GlideWear® provides skin protection and shear reduction. Not fluid resistant. GLIDEWEAR® GLIDEWEAR (ADD $26.00)

Comfort-Tek® provides fluid protection and is an easily cleaned surface. COMFORT-TEK® COMFORT-TEK

Stretch-Air® provides air transmission and heat dissipation. STRETCH-AIR® STRETCH-AIR

L

W

$237.00/EA

11 BODILINK HEAD SUPPORT PAD STYLEHCPCS Code: E0955*Length (L) refers to the actual size dimension of the support from bottom to top edge.

12 BODILINK HEAD SUPPORT HARDWAREHCPCS Code: E1028

A. PT HARDWARE, REMOVABLE

PT

HA

RD

WA

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, M

ID 6

PT

HA

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AT

6

PT

HA

RD

WA

RE

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ID 8

PT

HA

RD

WA

RE

, L

AT

8

PT

HA

RD

WA

RE

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8

SHAPE MSRPMID 6 $223.00 BL-HS-PT1RMMID6

LAT 6 $260.00 BL-HS-PT1RMLAT6

MID 8 $223.00 BL-HS-PT1RMMID8

LAT 8 $260.00 BL-HS-PT1RMLAT8

MAX 8 $327.00 BL-HS-PT1RMMAX8

A1. PT HARDWARE STEM LENGTH OPTION

LENGTH MSRPSTANDARD 7” STEM $0.00 HS-STEM-7

*3” STEM $0.00 HS-STEM-3

ST

AN

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RD

PT

ST

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, 7

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PT

ST

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, 3

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A. PREMIUM PAD SIZE

6Wx3LSOFT BL-HSP1-6W3L

EXTRA SOFT BL-HSP2-6W3L

8W x 4LSOFT BL-HSP1-8W4L

EXTRA SOFT BL-HSP2-8W4L

Adjustable Wing 10W x 5L

SOFT BL-HSP1-10W5L

EXTRA SOFT BL-HSP2-10W5L

Adjustable Wing 12W x 5L

SOFT BL-HSP1-12W5L

EXTRA SOFT BL-HSP2-12W5L

Adjustable Wing 14W x 5L

SOFT BL-HSP1-14W5L

EXTRA SOFT BL-HSP2-14W5L

Adjustable Wing 18W x 5L

SOFT BL-HSP1-18W5L

EXTRA SOFT BL-HSP2-18W5L

You may make one selection per section A or B.If choosing hardware in section A, choose a stem length option in section A1.

(Input is case sensitive. Please enter exactly as you want the words to look. Example: Marcus or marcus or MARCUS)

*3” Stem is recommended for use with power mounting where there may be special constraints with power chair functions

CUSTOM ACTA-BACK DEEP ORDER FORM Client Reference: PAGE 3 of 3

*DO NOT SEND PROTECTED HEALTH INFORMATION. IT IS NOT NEEDED TO MAKE THE PRODUCT YOU ARE REQUESTING.*

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NOTES

13 BODILINK® HEAD SUPPORT MOUNTING OPTION

MOUNTING BLOCK-POSTERIOR A

14 ADDITIONAL WINGS AND LINKS

1/4” SPACER PLATE2” LINK 3” LINK

MSRPPOSTERIOR A

MOUNTING BLOCK $0.00 HS-MB-POSTA

MSRP*EXTRA 2” LINK $57.00 BL-HS-PT1LINK2

*EXTRA 3” LINK $57.00 BL-HS-PT1LINK3

*EXTRA 4” LINK $57.00 BL-HS-PT1LINK4

*TOOL-LESS WING LOCK $21.00/each BL-HS-52WINGA1 BL-HS-52WINGA1

BL-HS-52WINGA1 BL-HS-52WINGA1

1/4” SPACER PLATE $37.00 BL-HS-SPCRA

4” LINK TOOL-LESSWING LOCK

The following are trademarks and registered trademarks of Permobil Seating and Positioning: ACTA-BACK®, BodiLink®, Comfort-Tek®, Compass®, and Stretch-Air®.Glidewear® is a registered trademark of Tamarack Habilitation Technologies, Inc. Viscool® is a registered trademark of American Excelsior Company, Inc.

B. PT HARDWARE, FLIP-DOWN

PT H

ARD

WAR

E, M

ID 6

PT H

ARD

WAR

E, L

AT 6

PT H

ARD

WAR

E, M

ID 8

PT H

ARD

WAR

E, L

AT 8

PT H

ARD

WAR

E, M

AX 8

SHAPE MSRPMID 6 $273.00 BL-HS-PT1FDMID6

LAT 6 $310.00 BL-HS-PT1FDLAT6

MID 8 $273.00 BL-HS-PT1FDMID8

LAT 8 $310.00 BL-HS-PT1FDLAT8

MAX 8 $357.00 BL-HS-PT1FDMAX8

SUBMIT BY EMAIL

*For PT Hardware Only