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CUSTOM ACTA-RELIEF™ - SHORT ORDER FORM HCPCS CODE: E2617

1 BACK SUPPORT SIZE

C - R - 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” 14”W-16”W 1 BAG

3” 18”W-20”W 1½ BAG

4” 14”W 1 BAG

4” 16”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

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:

$0.00 $0.00 $0.00 $0.00

REAR LAYER (REQUIRED)

$0.00H.R. MEDIUM

1/4” (CD-REAR-HRM-0.25)

1/2” (CD-REAR-HRM-0.50) SFC3/4” (CD-REAR-HRM-0.75)

1” (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)

1” (CD-TOP-VIS-XXS-1.00) SFC

$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 and Boa® appearance may vary with hardware and size selection. Acta-Relief™ is limited to the sizes shown.

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 ARMY(CD-ARMY-PATCH)

AIR FORCE(CD-AIR-FORCE-PATCH)

NAVY(CD-NAVY-PATCH)

MARINES(CD-MARINES-PATCH)

(OPTIONAL)

CD

-AC

TA-R

ELI

EF-

SHO

RTF

OR

M

RE

V05

18

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 customs@comfortcompany.com or print and fax to 1.406.522.8563.

Patent Pending

Leng

th

22”20”18”16”14”12”10”

14” 16” 18” 20”Width

$1,692.00

12”L back supports are not available with 4 PT hardware when using lateral trunk supports. 10”L Acta-Relief back supports are not available with 4 PT or Power Mount hardware, lateral trunk supports or a head support.

SFC = Standard Foam Configuration. Use as a reference when choosing foam layers. Keep in mind that thicker or firmer foams may decrease the level of patient immersion.

=1” (CD-TOP-VIS-XXS-1.00) SFC

7 COLOR (OPTIONAL) $0.00

RED (CD-RED)

PURPLE (CD-PURPLE)

PINK (CD-PINK)

BLUE (CD-BLUE)

GREEN (CD-GREEN)

REMOVE (CD-REMOVE)

THREAD COLOR

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

PRIVACY 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

WORD(S)

Helvetica (CD-EMB-HELVETICA)

Garamond (CD-EMB-GARAMOND)

(CD-EMB-TWILIGHT)

(CD-EMB-SCRIPT)

WORD ONE

WORD TWO

A. B.

C.

8 PRIVACY FLAP (OPTIONAL) 9 EMBROIDERY (OPTIONAL) $0.00$35.00

6 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

2/4

COLOR LOCATION

CD-ACTA-RELIEF-SHORTFORM REV0518

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 (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 10”L back supports *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

10 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. GT1 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

ORANGE (CD-ORANGE)

11 BODILINK® LTS HARDWARE

12 ADDITIONAL LTS HARDWARE

GT

GT

GT2

GT2

Not available on all sizes. See restrictions on page 1 by size chart.*”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

$271.00ea.

LEFT BL-LTS-GT1SAK-LH

*EXTRA LEFT BL-LTS-GT1SAK-LH

RIGHT BL-LTS-GT1SAK-RH

*EXTRA RIGHT BL-LTS-GT1SAK-RH

FIXED

FIX

ED SLOT

MOUNT$129.00ea.

LEFT BL-LTS-GT1FXK-LH

*EXTRA LEFT BL-LTS-GT1FXK-LH

RIGHT BL-LTS-GT1FXK-RH

*EXTRA RIGHT BL-LTS-GT1FXK-RH

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

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

SWING-AWAY HCPCS Code: E1028

SWIN

G-A

WA

Y

Open Position

SLOT MOUNT

$298.00ea.

LEFT BL-LTS-GT2SAK-LH

*EXTRA LEFT BL-LTS-GT2SAK-LH

RIGHT BL-LTS-GT2SAK-RH

*EXTRA RIGHT BL-LTS-GT2SAK-RH

FIXED

FIX

ED SLOT

MOUNT$178.00ea.

LEFT BL-LTS-GT2FXK-LH

*EXTRA LEFT BL-LTS-GT2FXK-LH

RIGHT BL-LTS-GT2FXK-RH

*EXTRA RIGHT BL-LTS-GT2FXK-RH

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

13 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

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

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

3/4CD-ACTA-RELIEF-SHORTFORM REV0518

SHAPE MSRPMID 8 $223.00 BL-HS-PT1RMMID8

LAT 8 $260.00 BL-HS-PT1RMLAT8

MAX 8 $327.00 BL-HS-PT1RMMAX8

MID 6 $223.00 BL-HS-PT1RMMID6

LAT 6 $260.00 BL-HS-PT1RMLAT6

NOTES

4/4CD-ACTA-RELIEF-SHORTFORM REV0318

SUBMIT BY EMAIL

14 BODILINK® HEAD SUPPORT HARDWAREHCPCS Code: E1028

15 BODILINK® HEAD SUPPORT MOUNTING OPTION

16 EXTRA HARDWARE

1/4” SPACER PLATE

2” LINK 3” LINK

Make a selection in sections A -or- B.

A. PT HARDWARE, REMOVABLE

PT

HA

RD

WA

RE

, 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

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

”

MSRP*Acta-Relief™ 14W Bracket

with Mounting Block $72.00 HS-MB-AR14W

*Acta-Relief™ 16W Bracket with Mounting Block $72.00 HS-MB-AR16W

*Acta-Relief™ 18W Bracket with Mounting Block $72.00 HS-MB-AR18W

*Acta-Relief™ 20W Bracket with Mounting Block $72.00 HS-MB-AR20W

POSTERIOR 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

4” LINK TOOL-LESSWING LOCK

MSRP

*Acta-Relief™ 14W Bracket $152.00 BL-HS-AR14W

*Acta-Relief™ 16W Bracket $152.00 BL-HS-AR16W

*Acta-Relief™ 18W Bracket $152.00 BL-HS-AR18W

*Acta-Relief™ 20W Bracket $152.00 BL-HS-AR20W

1/4” SPACER PLATE $37.00 BL-HS-SPCRA

*Does not include a posterior mounting block. Mounting Bracket only. Purchase

required when using a non-Comfort Company head support with COMPASS® 4

(2 Point or 4 Point) Hardware.

BRACKET AND MOUNTING BLOCK-

ACTA-RELIEF™18W Shown Above

*For Non-Power Mount Only.*

BRACKET-ACTA-RELIEF™

18W Shown Above

**For PT Hardware Only

MOUNTING BLOCK-POSTERIOR A

For *Acta-Relief with Power Mount Only*

* For Acta Relief™, includes mounting bracket and POSTA block. If you already have an Acta-Relief™ head support bracket, order POSTA Block

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