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

1 BACK SUPPORT SIZE

C - A - 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 BAG3” 17”W-22”W 1½ BAG4” 10”W-14”W 1 BAG4” 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:

Client Reference:

10-20” Width / 10-18” Length = $923 Base Price21-24” Width / 10-18” Length = $1014 Base Price10-24” Width / 19-22” Length = $1042 Base Price25-28” Width / 10-22” Length = $1497 Base Price*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)

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)

$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

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

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.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.

3 MILITARY BRANCH PATCH *OPTIONAL*

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

*Please note that 10L sizes are not available with lateral trunk supports or a head support.

®*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.*

AIR FORCE $0.00 ARMY $0.00 MARINES $0.00 NAVY $0.00(CD-AIR-FORCE-PATCH) (CD-ARMY-PATCH) (CD-MARINES-PATCH) (CD-NAVY-PATCH)

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

CUSTOM ACTA-BACK 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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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)

SPECIFY CUSTOM SPACING(CD-STAY-OTHER)

NONE (CD-STAY-NONE)

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.

8 COLOR *OPTIONAL*COLOR $0.00

RED (CD-RED)

PURPLE (CD-PURPLE)

PINK (CD-PINK)

BLUE (CD-BLUE)

GREEN (CD-GREEN)

REMOVE (CD-REMOVE)

$0.00THREAD COLOR OPTIONS

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

$35.00PRIVACY FLAP (CD-PF-CV)

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.

9 PRIVACY FLAP *OPTIONAL* 10 EMBROIDERY *OPTIONAL*

$0.00

7 HARDWARE OPTIONS

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.

Privacy Flap

11 BODILINK LATERAL TRUNK SUPPORT PAD STYLE

PREMIUM STYLE

Aluminum Stay Pockets

Moldable Aluminum Stays

COLOR LOCATION

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.

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, or sizes 12Wx16L & 12Wx18L*Power Mount Bracket required for all power chairs listed below.

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)

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)

$0.00

$0.00

$0.00

$0.00

$515.00

$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

COMPASS® 4 MOUNTING HARDWARE

ORANGE (CD-ORANGE)

12 BODILINK LTS HARDWARE

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

A. SIZE & SHAPESHAPE SIZE LEFT RIGHT

SUPP

ORT

IVE

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

ACT

IVE 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-CV

COMFORT-TEK® $0 LTS-P2-COMFORT LTS-P2-COMFORT

STRETCH-AIR® $0 LTS-P2-STRETCH LTS-P2-STRETCH

GLIDEWEAR® $13.00ea. LTS-P2-GLIDE LTS-P2-GLIDE

COMFORT-TEK® w/ FOAM $13.00ea. LTS-P2-COMFORT-FM LTS-P2-COMFORT-FM

STRETCH-AIR® w/ FOAM $13.00ea. LTS-P2-STRETCH-FM LTS-P2-STRETCH-FM

GLIDEWEAR® 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. Follow each column down to sections B and C and select a style and cover for each pad selected in section A.

HCPCS Code: E0956

- OR -

$88.00ea.*EXTRA LEFT *EXTRA RIGHT

*EXTRA LEFT *EXTRA RIGHT

*EXTRA LEFT *EXTRA RIGHT

GT2

Slot Mount not available on 12”L or smaller Acta-Backs®.Track Mount only to be used with Compass® 4 Hardware (no 4PT on 10L - 14L backs.)*”EXTRA” parts may not fit depending on back support, pad, and hardware size and style combinations (especially back supports 16’L or less).

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

TRACK MOUNT

$298.00ea.

LEFT BL-LTS-GT2SAT-LH

*EXTRA LEFT BL-LTS-GT2SATX-LH

RIGHT BL-LTS-GT2SAT-RH

*EXTRA RIGHT BL-LTS-GT2SATX-RH

FIXED

FIXE

D

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

TRACK MOUNT

$178.00ea.

LEFT BL-LTS-GT2FXT-LH

*EXTRA LEFT BL-LTS-GT2FXTX-LH

RIGHT BL-LTS-GT2FXT-RH

*EXTRA RIGHT BL-LTS-GT2FXTX-RH

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

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14 BODILINK® HEAD SUPPORT PAD

13 ADDITIONAL LTS HARDWARE

HCPCS Code: E0955*Length (L) refers to the actual size dimension of the support from bottom to top edge.

$237.00/EA

15 BODILINK HEAD SUPPORT HARDWAREHCPCS Code: E1028

16 HEAD SUPPORT MOUNTING OPTION

MOUNTING BLOCK-POSTERIOR A

17 EXTRA HARDWARE

1/4” SPACER PLATE2” LINK 3” LINK

NOTES

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

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

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

Additional LTS hardware will only work with their designated hardware style.

L

W

A. PT HARDWARE, REMOVABLE

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 $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

STAN

DAR

DPT

STE

M, 7

”

PT S

TEM

, 3”

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

MSRPPOSTERIOR A

MOUNTING BLOCK $0.00 HS-MB-POSTA

MSRPEXTRA 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 $36.00 BL-HS-SPCRA

4” LINK TOOL-LESSWING LOCK

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

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

SUBMIT BY EMAILThe 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.