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CUSTOM ACTA-EMBRACE® BACK - SHORT ORDER FORM HCPCS CODE: E2617
1/5
1 BACK SUPPORT SIZE
C - E - W HHCPCS Code: E2617
4 CUSTOM FOAM SELECTION
Rear LayerMiddle Layer
Topper Layer
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.
5 FOAM IN PLACE KIT
EXTRA SOFT MEMORY FOAM
1 BAG (CD-FIP3-1-XS)
1 1/2 BAG (CD-FIP3-1.5-XS)
3” BACK BORDER
1 BAG (CD-FIP4-1-XS)
1 1/2 BAG (CD-FIP4-1.5-XS)
4” BACK BORDER
SOFT MEMORY FOAM
1 BAG (CD-FIP3-1-S)
1 1/2 BAG (CD-FIP3-1.5-S)
3” BACK BORDER
1 BAG (CD-FIP4-1-S)
1 1/2 BAG (CD-FIP4-1.5-S)
4” BACK BORDER
MEDIUM MEMORY FOAM
1 BAG (CD-FIP3-1-M)
1 1/2 BAG (CD-FIP3-1.5-M)
3” BACK BORDER
1 BAG (CD-FIP4-1-M)
1 1/2 BAG (CD-FIP4-1.5-M)
4” BACK BORDER
BAG POUR SIZE RECOMMENDATION CHART
BORDERThickness
FRAME WIDTH
RECOMMENDED 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
KIT INCLUDES: • 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.)
3-4” Border
Aluminum Stays
Gap for Foam in Place
Pleates
1” Viscool Medium
½” Viscool Soft
$309.00$412.00
$309.00$412.00
$309.00$412.00
$309.00$412.00
$309.00$412.00
$309.00$412.00
Company Name/ACCT #:
P.O. Number:
Requested By:
Phone: Fax:
Email:
Ship To:
Patient Reference:
10-20” Width / 10-18” Length = $923 Base Price21-24” Width / 10-18” Length = $1014 Base Price10-24” Width / 19-22” Length = $1043 Base Price25-28” Width / 10-22” Length = $1497 Base Price
$0.00 $0.00 $0.00 $0.00
*If desired size is not listed above, a 60% up charge will be applied for materials.
REAR LAYER (REQUIRED)
$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)
VISCOOLTM MEDIUM
1/2” (CD-REAR-VIS-M-0.50)
1” (CD-REAR-VIS-M-1.00)
VISCOOLTM SOFT
1/2” (CD-REAR-VIS-S-0.50)
1” (CD-REAR-VIS-S-1.00)
VISCOOLTM 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)
VISCOOLTM MEDIUM
1/2” (CD-MID-VIS-M-0.50)
1” (CD-MID-VIS-M-1.00)
VISCOOLTM SOFT
1/2” (CD-MID-VIS-S-0.50)
1” (CD-MID-VIS-S-1.00)
VISCOOLTM 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)
VISCOOLTM MEDIUM
1/2” (CD-TOP-VIS-M-0.50)
1” (CD-TOP-VIS-M-1.00)
VISCOOLTM SOFT
1/2” (CD-TOP-VIS-S-0.50)
1” (CD-TOP-VIS-S-1.00)
VISCOOLTM 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)
$0.00
$138.00
$138.00
$133.33
$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
2 COVER OPTIONS
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
Choose either Stretch-Air or Comfort-Tek cover fabric with Diamond or Digi-Camo accent fabric. Care for each accent fabric is identical.
3 MILITARY BRANCH PATCH ARMY(CD-ARMY-PATCH)
AIR FORCE(CD-AIR-FORCE-PATCH)
NAVY(CD-NAVY-PATCH)
MARINES(CD-MARINES-PATCH)
(OPTIONAL)
CD
-AC
TA-E
MB
RA
CE
-SH
OR
TFO
RM
R
EV
0418
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 [email protected] or print and fax to 1.406.522.8563.
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.
Standard foam layer thicknesses reduce to 3/8” on sizes 10-14L.
SFC = Standard Foam Configuration. Use as a reference when choosing foam layers. =1” (CD-TOP-VIS-XXS-1.00) SFC
CONTOURED WING
LINEAR WING
9 COLOR
COLOR
$0.00
RED (CD-RED)
PURPLE (CD-PURPLE)
PINK (CD-PINK)
BLUE (CD-BLUE)
GREEN (CD-GREEN)
REMOVE (CD-REMOVE)
7 BACK SUPPORT WING STYLE
$0.00
THREAD 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 OPTIONS
Helvetica (CD-EMB-HELVETICA)
Garamond (CD-EMB-GARAMOND)
(CD-EMB-TWILIGHT)
(CD-EMB-SCRIPT)
WORD ONE
WORD TWO
A. B.
10 EMBROIDERY
GROWTH KIT INCLUDES:• 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.
$344.002” GROWTH PLATE With ADD’L FOAM & COVER (CD-2”GK)
11 GROWTH KIT
$344.004” GROWTH PLATE With ADD’L FOAM & COVER (CD-4”GK)
8 HARDWARE OPTIONS
Accent colors are applied via colored piping. If no color is selected, our standard reflective piping will be used.
2” or 4” Growth Plate
Cushion Foam
Contoured wings are needed to mount Lateral Trunk Supports and Winter/Summer Hardware. Both styles of wing are height and width adjustable
$0.00 (Extra Wings $69.00ea.)
Wing Length
Wing Length
COLOR LOCATION
6 MOLDABLE ALUMINUM STAYSSPACE BETWEEN STAYS
1” (CD-STAY-1.0)
1 1/2” (CD-STAY-1.5)
$0.00
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)
NONE (CD-STAY-NONE)
SPECIFY CUSTOM SPACING(CD-STAY-OTHER)
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.
Aluminum Stay Pockets
Moldable Aluminum Stays
2/5CD-ACTA-EMBRACE-SHORTFORM REV0418
*Length (L) refers to the actual size dimension of the support from bottom to top edge.
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 RELEASE COMPASS® 4 (4 PT)(CD-Q-COMPASS4)
$0.00
QUICK RELEASE COMPASS® 4 (2 PT)(CD-Q-COMPASS)
$0.00
FIXED COMPASS® 4 (2 PT)(CD-NQ-COMPASS)
$0.00
FIXED COMPASS® 4 (4 PT)(CD-NQ-COMPASS4)
$0.00
COMPASS® 4 BUNDLE(2 PT, 4 PT, QUICK RELEASE & FIXED)(CD-COMPASS-BUNDLE)
$481.00
COMPASS® 4 MOUNTING HARDWARE
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”L or 12” W.*Power Mount Bracket required for all power chairs listed below.
QUANTUM with TRU BALANCE 3(CD-PMB-QUANTUM)
$515.00
PERMOBIL with CORPUS 3G(CD-PMB-PERMOBIL)
$515.00
QUICKIE with 3.7 POWER(CD-PMB-QUICKIE)
$515.00
AVID REHAB with POWER T & R(CD-PMB-AVID)
$515.00
ROVI with MOTION CONCEPTS*(CD-PMB-ROVI)
$515.00
*Using Compass® Power Mount on Rovi requires mounting to the RECESSED PLANAR INTERFACE PLATE available when ordering the Motion Concepts Seating System. Drill-ing is required for mounting.
COMPASS® POWER MOUNT BRACKET
SIZE LEFT5”L (CD-LEFTWING-5-CON)
6”L (CD-LEFTWING-6-CON)
8”L (CD-LEFTWING-8-CON)
EXTRA LEFT5”L (CD-ADD-L-WING-5-CON)
6”L (CD-ADD-L-WING-6-CON)
8”L (CD-ADD-L-WING-8-CON)
RIGHT5”L (CD-RIGHTWING-5-CON)
6”L (CD-RIGHTWING-6-CON)
8”L (CD-RIGHTWING-8-CON)
EXTRA RIGHT5”L (CD-ADD-R-WING-5-CON)
6”L (CD-ADD-R-WING-6-CON)
8”L (CD-ADD-R-WING-8-CON)
SIZE LEFT5”L (CD-LEFTWING-5-LIN)
6”L (CD-LEFTWING-6-LIN)
8”L (CD-LEFTWING-8-LIN)
EXTRA LEFT5”L (CD-ADD-L-WING-5-LIN)
6”L (CD-ADD-L-WING-6-LIN)
8”L (CD-ADD-L-WING-8-LIN)
RIGHT5”L (CD-RIGHTWING-5-LIN)
6”L (CD-RIGHTWING-6-LIN)
8”L (CD-RIGHTWING-8-LIN)
EXTRA RIGHT5”L (CD-ADD-R-WING-5-LIN)
6”L (CD-ADD-R-WING-6-LIN)
8”L (CD-ADD-R-WING-8-LIN)
Back Length Wing Length
10”L - 12”L Back 5”L Wing13”L - 16”L Back 6”L Wing17”L - 22”L Back 8”L Wing
WING SIZE RECOMMENDATION
CHART
ORANGE (CD-ORANGE)
3/5CD-ACTA-EMBRACE-SHORTFORM REV0418
14 BODILINK® LATERAL TRUNK SUPPORT PAD STYLE
BASIC STYLE PREMIUM STYLE
A. SIZE & SHAPESHAPE SIZE LEFT RIGHT
SUP
PO
RTI
VE
L
D
3”L x 4”D BL-LTSP1S-3L4D-LH BL-LTSP1S-3L4D-RH3”L x 5”D BL-LTSP1S-3L5D-LH BL-LTSP1S-3L5D-RH4”L x 5”D BL-LTSP1S-4L5D-LH BL-LTSP1S-4L5D-RH4”L x 6”D BL-LTSP1S-4L6D-LH BL-LTSP1S-4L6D-RH5”L x 7”D BL-LTSP1S-5L7D-LH BL-LTSP1S-5L7D-RH6”L x 6”D BL-LTSP1S-6L6D-LH BL-LTSP1S-6L6D-RH
AC
TIV
E L
D
3”L x 4”D BL-LTSP1A-3L4D-LH BL-LTSP1A-3L4D-RH3”L x 5”D BL-LTSP1A-3L5D-LH BL-LTSP1A-3L5D-RH4”L x 5”D BL-LTSP1A-4L5D-LH BL-LTSP1A-4L5D-RH4”L x 6”D BL-LTSP1A-4L6D-LH BL-LTSP1A-4L6D-RH5”L x 7”D BL-LTSP1A-5L7D-LH BL-LTSP1A-5L7D-RH6”L x 6”D BL-LTSP1A-6L6D-LH BL-LTSP1A-6L6D-RH
B. STYLE STYLE LEFT RIGHT
MOLDABLE LTS-P1-MOLD LTS-P1-MOLD
RIGID LTS-P1-RIGID LTS-P1-RIGID
C. COVERCOVER LEFT RIGHT
COMFORT-TEK™ LTS-P1-COMFORT LTS-P1-COMFORTSTRETCH-AIR™ LTS-P1-STRETCH LTS-P1-STRETCH
A. SIZE & SHAPESHAPE SIZE LEFT RIGHT
SUP
PO
RTI
VE
L
D
3”L x 4”D BL-LTSP2S-3L4D-LH BL-LTSP2S-3L4D-RH
3”L x 5”D BL-LTSP2S-3L5D-LH BL-LTSP2S-3L5D-RH
4”L x 5”D BL-LTSP2S-4L5D-LH BL-LTSP2S-4L5D-RH
4”L x 6.5”D BL-LTSP2S-4L6D-LH BL-LTSP2S-4L6D-RH
5”L x 6.5”D BL-LTSP2S-5L6D-LH BL-LTSP2S-5L6D-RH
6”L x 6.5”D BL-LTSP2S-6L6D-LH BL-LTSP2S-6L6D-RH
AC
TIV
E L
D
3”L x 4”D BL-LTSP2A-3L4D-LH BL-LTSP2A-3L4D-RH
3”L x 5”D BL-LTSP2A-3L5D-LH BL-LTSP2A-3L5D-RH
4”L x 5”D BL-LTSP2A-4L5D-LH BL-LTSP2A-4L5D-RH
4”L x 6.5”D BL-LTSP2A-4L6D-LH BL-LTSP2A-4L6D-RH
5”L x 6.5”D BL-LTSP2A-5L6D-LH BL-LTSP2A-5L6D-RH
6”L x 6.5”D BL-LTSP2A-6L6D-LH BL-LTSP2A-6L6D-RH
B. STYLE STYLE LEFT RIGHT
MOLDABLE LTS-P2-MOLD LTS-P2-MOLD
RIGID LTS-P2-RIGID LTS-P2-RIGID
C. COVERCOVER MSRP LEFT RIGHT
NO COVER $0 LTS-P2-NO-CV LTS-P2-NO-CVCOMFORT-TEK™ $0 LTS-P2-COMFORT LTS-P2-COMFORTSTRETCH-AIR™ $0 LTS-P2-STRETCH LTS-P2-STRETCHGLIDEWEAR™ $13.00ea. LTS-P2-GLIDE LTS-P2-GLIDE
COMFORT-TEK w/ FOAM $13.00ea. LTS-P2-COMFORT-FM LTS-P2-COMFORT-FMSTRETCH-AIR w/ FOAM $13.00ea. LTS-P2-STRETCH-FM LTS-P2-STRETCH-FMGLIDEWEAR w/ FOAM $26.00ea. LTS-P2-GLIDE-FM LTS-P2-GLIDE-FM
You may make one selection per column (Left, Extra Left, 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
HCPCS Code: E0956
- OR - - OR -
$82.00ea. $88.00ea.*EXTRA LEFT *EXTRA LEFT*EXTRA RIGHT *EXTRA RIGHT
*EXTRA LEFT *EXTRA LEFT*EXTRA RIGHT *EXTRA RIGHT
*EXTRA LEFT *EXTRA LEFT*EXTRA RIGHT *EXTRA RIGHT
*”EXTRA” parts may not fit depending on back support, pad, and hardware size and style combinations (especially back supports 16’L or less). Please contact customer support with questions. 1.800.564.9248
15 BODILINK® LTS HARDWARE*”EXTRA” parts may not fit depending on back support, pad, and hardware size and style combinations.
GT GT2
SWING-AWAY HCPCS Code: E1028
SWIN
G-A
WA
Y
Open Position
SLOT MOUNT$271.00ea.
LEFT BL-LTS-GT1SAS-LH
**EXTRA LEFT BL-LTS-GT1SAS-LH
RIGHT BL-LTS-GT1SAS-RH
**EXTRA RIGHT BL-LTS-GT1SAS-RH
SLOT MOUNT w/ WINTER/SUMMER
$425.00ea.
LEFT BL-LTS-GT1SAWSAE-LH
**EXTRA LEFT BL-LTS-GT1SAWSAE-LH
RIGHT BL-LTS-GT1SAWSAE-RH
**EXTRA RIGHT BL-LTS-GT1SAWSAE-RH
**Extra Contoured Wing needed (Section 7) to mount extra lateral hardware.
FIXED
FIX
ED
SLOT MOUNT$129.00ea.
LEFT BL-LTS-GT1FXS-LH
**EXTRA LEFT BL-LTS-GT1FXS-LH
RIGHT BL-LTS-GT1FXS-RH
**EXTRA RIGHT BL-LTS-GT1FXS-RH
SLOT MOUNT w/ WINTER/SUMMER
$283.00ea.
LEFT BL-LTS-GT1FXWSAE-LH
**EXTRA LEFT BL-LTS-GT1FXWSAE-LH
RIGHT BL-LTS-GT1FXWSAE-RH
**EXTRA RIGHT BL-LTS-GT1FXWSAE-RH
**Extra Contoured Wing needed (Section 7) to mount extra lateral hardware.
SWING-AWAY HCPCS Code: E1028
SWIN
G-A
WA
Y
Open Position
SLOT MOUNT$298.00ea.
LEFT BL-LTS-GT2SAS-LH
**EXTRA LEFT BL-LTS-GT2SAS-LH
RIGHT BL-LTS-GT2SAS-RH
**EXTRA RIGHT BL-LTS-GT2SAS-RH
SLOT MOUNT w/ WINTER/SUMMER
$452.00ea.
LEFT BL-LTS-GT2SAWSAE-LH
**EXTRA LEFT BL-LTS-GT2SAWSAE-LH
RIGHT BL-LTS-GT2SAWSAE-RH
**EXTRA RIGHT BL-LTS-GT2SAWSAE-RH
**Extra Contoured Wing needed (Section 7) to mount extra lateral hardware.
FIXED
FIX
ED
SLOT MOUNT$178.00ea.
LEFT BL-LTS-GT2FXS-LH
**EXTRA LEFT BL-LTS-GT2FXS-LH
RIGHT BL-LTS-GT2FXS-RH
**EXTRA RIGHT BL-LTS-GT2FXS-RH
SLOT MOUNT w/ WINTER/SUMMER
$332.00ea.
LEFT BL-LTS-GT2FXWSAE-LH
**EXTRA LEFT BL-LTS-GT2FXWSAE-LH
RIGHT BL-LTS-GT2FXWSAE-RH
**EXTRA RIGHT BL-LTS-GT2FXWSAE-RH
**Extra Contoured Wing needed (Section 7) to mount extra lateral hardware.
Privacy Flap connects with hook and loop attachment between the seat and back support for added privacy.
$35.00PRIVACY FLAP (CD-PF-CV)
12 PRIVACY FLAP
Up to 1 1/2” wide webbing.$61.00EXTRA SMALL (CHG2-EB1)
13 STRAP EXTENSION GUIDE BRACKET
Up to 2 1/4” wide webbing.$61.00SMALL (CHG2-EB2)
Privacy Flap
Strap Extension Guide Bracket
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
4/5CD-ACTA-EMBRACE-SHORTFORM REV0418
16 ADDITIONAL LTS HARDWARE
GT
GT2
EXTRA HARDWARE LINKS1”
$37.00ea.
LEFT BL-LTS-GT1LINK
ADDITIONAL LEFT BL-LTS-GT1LINK
RIGHT BL-LTS-GT1LINK
ADDITIONAL RIGHT BL-LTS-GT1LINK
HARDWARE COVER
$26.00ea.
LEFT BL-LTS-HCOVER
EXTRA LEFT BL-LTS-HCOVER
RIGHT BL-LTS-HCOVER
EXTRA RIGHT BL-LTS-HCOVER
WINTER/SUMMER HARDWARE**
$154.00ea.
LEFT BL-LTS-HWSAE-LH
EXTRA LEFT BL-LTS-HWSAE-LH
RIGHT BL-LTS-HWSAE-RH
EXTRA RIGHT BL-LTS-HWSAE-RH
**Extra Contoured Wing needed (Section 7) to mount extra Winter/Summer hardware.
EXTRA HARDWARE LINKS1¼”
$37.00ea.
LEFT BL-LTS-GT2LINK
ADDITIONAL LEFT BL-LTS-GT2LINK
RIGHT BL-LTS-GT2LINK
ADDITIONAL RIGHT BL-LTS-GT2LINK
LONG MOUNTING BRACKET
adds 1” of adjustment per bracket
$37.00ea.
LEFT BL-LTS-GT2LSLOT-LH
EXTRA LEFT BL-LTS-GT2LSLOT-LH
RIGHT BL-LTS-GT2LSLOT-RH
EXTRA RIGHT BL-LTS-GT2LSLOT-RH
HARDWARE COVER
$26.00ea.
LEFT BL-LTS-HCOVER
EXTRA LEFT BL-LTS-HCOVER
RIGHT BL-LTS-HCOVER
EXTRA RIGHT BL-LTS-HCOVER
WINTER/SUMMER HARDWARE**
$154.00ea.
LEFT BL-LTS-HWSAE-LH
EXTRA LEFT BL-LTS-HWSAE-LH
RIGHT BL-LTS-HWSAE-RH
EXTRA RIGHT BL-LTS-HWSAE-RH
**Extra Contoured Wing needed (Section 7) to mount extra Winter/Summer hardware.
Extra links and long mounting bracket will only work with their designated hardware style.
17 BODILINK® HEAD SUPPORT PADHCPCS Code: E0955
*Length (L) refers to the actual size dimension of the support from bottom to top edge.
$237.00/EA
$129.00/EA
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
L
W
Make a selection in sections A -or- B.
B1. BASIC PAD COVER MATERIAL
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
B. BASIC PAD SIZE
6Wx5L BL-HSP3-6W3L
8W x 5L BL-HSP3-8W5L
10W x 6L BL-HSP3-10W6L
12W x 6L BL-HSP3-12W6L
14W x 6L BL-HSP3-14W6L
14W x 6L BL-HSP3-18W6L
L
W
SUBMIT BY EMAIL
NOTES
5/5CD-ACTA-EMBRACE-SHORTFORM REV0418
18 BODILINK® HEAD SUPPORT HARDWAREHCPCS Code: E1028
19 BODILINK® HEAD SUPPORT MOUNTING OPTION
MOUNTING BLOCK-POSTERIOR A
20 EXTRA HARDWARE
1/4” SPACER PLATE2” LINK 3” LINK
Make a selection in sections A -or- B.
A. PT HARDWARE, REMOVABLEP
T H
AR
DW
AR
E, M
ID 6
PT
HA
RD
WA
RE
, L
AT
6
PT
HA
RD
WA
RE
, M
ID 8
PT
HA
RD
WA
RE
, L
AT
8
PT
HA
RD
WA
RE
, M
AX
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
B. GT HARDWARE, REMOVABLE
SHAPE MSRPLATERAL $228.00 BL-HS-GT3RMLAT
MID-LINE $191.00 BL-HS-GT3RMMID
GT
HA
RD
WA
RE
, L
AT
ER
AL
GT
HA
RD
WA
RE
, M
ID-L
INE
A1. PT HARDWARE STEM LENGTH OPTION
LENGTH MSRPSTANDARD 7” STEM $0.00 HS-STEM-7
*3” STEM $0.00 HS-STEM-3
ST
AN
DA
RD
PT
ST
EM
, 7
”
PT
ST
EM
, 3
”
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
*PT Hardware Only
* 3” Stem is recommended for use with power mounting where there may be special constraints with power chair functions