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PRIDE TB3 ACTA-BACK® DEEP
SEATING SYSTEM
HCPCS CODING: E2615/E2616POSITIONING BACK, POSTERIOR LATERAL
ORDER FORM 1 of 3Patient Reference:ACTA-BACK DEEP TB3 ORDER FORM
ORDER FORM
STRETCH AIR
STRETCH AIR
SELECTED FOR AIR TRANSMISSION & HEAT DISSIPATION. PROVIDES NO INCONTINENCE PROTECTION.
COMFORT TEK
COMFORT TEK
SELECTED FOR INCONTINENCE PROTECTION & AN EASILY CLEANED SURFACE.
OR
FRAME WIDTH
BK-M3D-22FP3-16
BK-M3D-22FP3-18
BK-M3D-22FP3-20
BK-M3D-22FP3-22
BK-M3D-22FP3-24
BK-M3D-20FP3-14
BK-M3D-20FP3-16
BK-M3D-20FP3-18
BK-M3D-20FP3-20
BK-M3D-20FP3-22
BK-M3D-20FP3-24
BK-M3D-18FP3-14
BK-M3D-18FP3-16
BK-M3D-18FP3-18
BK-M3D-18FP3-20
BK-M3D-18FP3-22
BK-M3D-18FP3-24
BK-M3D-16FP3-14
BK-M3D-16FP3-16
BK-M3D-16FP3-18
BK-M3D-16FP3-20
BK-M3D-16FP3-22
BK-M3D-14FP3-12
BK-M3D-14FP3-14
BK-M3D-14FP3-16
BK-M3D-14FP3-18
BK-M3D-14FP3-20
BK-M3D-12FP3-12
BK-M3D-12FP3-14
BK-M3D-12FP3-16
BK-M3D-12FP3-18
16”
18”
20”
16” 18” 20” 22”
$60100 $67700
12” 14”
14”
12”
24”
22”
$67800 $75400
16” 18” 20”12” 14” 22” 24”
FRAME WIDTH
BK-M3D-22UP3-16
BK-M3D-22UP3-18
BK-M3D-22UP3-20
BK-M3D-22UP3-22
BK-M3D-22UP3-24
BK-M3D-20UP3-14
BK-M3D-20UP3-16
BK-M3D-20UP3-18
BK-M3D-20UP3-20
BK-M3D-20UP3-22
BK-M3D-20UP3-24
BK-M3D-18UP3-14
BK-M3D-18UP3-16
BK-M3D-18UP3-18
BK-M3D-18UP3-20
BK-M3D-18UP3-22
BK-M3D-18UP3-24
BK-M3D-16UP3-14
BK-M3D-16UP3-16
BK-M3D-16UP3-18
BK-M3D-16UP3-20
BK-M3D-16UP3-22
BK-M3D-14UP3-12
BK-M3D-14UP3-14
BK-M3D-14UP3-16
BK-M3D-14UP3-18
BK-M3D-14UP3-20
BK-M3D-12UP3-12
BK-M3D-12UP3-14
BK-M3D-12UP3-16
BK-M3D-12UP3-18
16”
18”
20”
16” 18” 20” 22”
$60100 $67700
12” 14”
14”
12”
24”
22”
$67800 $75400
16” 18” 20”12” 14” 22” 24”
3”D X 5”L WINGS
CONTINUE ON NEXT PAGE FOR LARGER WINGS
1 SIZE & COVER
Company Name/ACCT #:
P.O. Number:
Requested By:
Phone: Fax:
Email:
Ship To:
Patient Reference:
Pride recommends a gap between the seat pan and bottom of the backrest. Static or Tilt chair gap (3-4 inches) Recline or Tilt/Recline chair gap (6-7 inches) Comfort Company has built this recom-mended gap into the mounting bracket for TB3 chairs to achieve the target back height. Additional adjustments may be made to the chair by changing the peg placement if desired.
BACKREST SIZE SELECTION
TB3-
AC
TA-B
AC
K-D
EE
P-F
OR
M R
EV
0116
BA
CK
RE
ST L
EN
GTH
BA
CK
RE
ST L
EN
GTH
*Length (L) refers to the actual size dimension of the support from bottom to top edge.
STATIC or TILT CHAIRS RECLINE or TILT/RECLINE CHAIRS
DESIRED BACK HEIGHT
(Seat pan to top of back shell)
RECOMMENDED CC BACKREST
LENGTH*
DESIRED BACK HEIGHT
(Seat pan to top of back shell)
RECOMMENDED CC BACKREST
LENGTH*
26-28 in. 27-28 in. 22
24-25 in. 22 25-26 in. 20
22-23 in. 20 23-24 in. 18
20-21 in. 18 21-22 in. 16
18-19 in. 16 19-20 in. 14
16-17 in. 14 17-18 in. 12
14-15 in. 12 15-16 in.
BACK OPTIONS22.1
COLOR ACCENT
SILVER REFLECTIVE PIPING COMES STANDARD
Red (RED) Blue (BLUE)
Purple (PURPLE) Green (GREEN)
Pink (PINK) Remove (REMOVE)
2.2 EMBROIDERY*
WORD ONE
THREAD COLOR OPTIONS
Red (EMB-RED) Blue (EMB-BLUE)
Purple (EMB-PURPLE) Green (EMB-GREEN)
Pink (EMB-PINK) Silver (EMB-SILVER)
WORD TWO
- AND/OR -
A.
B.
C.
MSRP $25.00 MSRP $25.00 MSRP $35.00
FONT/STYLE OPTIONSHelvetica (EMB-Helvetica) (EMB-Twilight)
Garamond (EMB-Garamond) (EMB-Script)
*ADDITIONAL LEAD TIMES MAY APPLY
2.3PRIVACY FLAP
Privacy Flap (PV-FLAP)
This flap connects with hook/loop attachment between the seat and back for added privacy.
Privacy Flap
ORDER FORM 2 of 3Patient Reference:ACTA-BACK DEEP TB3 ORDER FORM
COLOR LOCATION
FRAME WIDTH
BK-M7D-22FP3-16
BK-M7D-22FP3-18
BK-M7D-22FP3-20
BK-M7D-22FP3-22
BK-M7D-22FP3-24
BK-M7D-20FP3-14
BK-M7D-20FP3-16
BK-M7D-20FP3-18
BK-M7D-20FP3-20
BK-M7D-20FP3-22
BK-M7D-20FP3-24
BK-M7D-18FP3-14
BK-M7D-18FP3-16
BK-M7D-18FP3-18
BK-M7D-18FP3-20
BK-M7D-18FP3-22
BK-M7D-18FP3-24
BK-M7D-16FP3-14
BK-M7D-16FP3-16
BK-M7D-16FP3-18
BK-M7D-16FP3-20
BK-M7D-16FP3-22
BK-M7D-14FP3-16
BK-M7D-14FP3-18
BK-M7D-14FP3-20
BK-M7D-12FP3-16
BK-M7D-12FP3-18
16”
18”
20”
16” 18” 20” 22”
$60100 $67700
12” 14”
14”
12”
24”
22”
$67800 $75400
16” 18” 20”12” 14” 22” 24”
FRAME WIDTH
BK-M7D-22UP3-16
BK-M7D-22UP3-18
BK-M7D-22UP3-20
BK-M7D-22UP3-22
BK-M7D-22UP3-24
BK-M7D-20UP3-14
BK-M7D-20UP3-16
BK-M7D-20UP3-18
BK-M7D-20UP3-20
BK-M7D-20UP3-22
BK-M7D-20UP3-24
BK-M7D-18UP3-14
BK-M7D-18UP3-16
BK-M7D-18UP3-18
BK-M7D-18UP3-20
BK-M7D-18UP3-22
BK-M7D-18UP3-24
BK-M7D-16UP3-14
BK-M7D-16UP3-16
BK-M7D-16UP3-18
BK-M7D-16UP3-20
BK-M7D-16UP3-22
BK-M7D-14UP3-16
BK-M7D-14UP3-18
BK-M7D-14UP3-20
BK-M7D-12UP3-16
BK-M7D-12UP3-18
16”
18”
20”
16” 18” 20” 22”
$60100 $67700
12” 14”
14”
12”
24”
22”
$67800 $75400
16” 18” 20”12” 14” 22” 24”
7”D X 7”L WINGS
STRETCH AIR COMFORT TEK
FRAME WIDTH
BK-M5D-22FP3-16
BK-M5D-22FP3-18
BK-M5D-22FP3-20
BK-M5D-22FP3-22
BK-M5D-22FP3-24
BK-M5D-20FP3-14
BK-M5D-20FP3-16
BK-M5D-20FP3-18
BK-M5D-20FP3-20
BK-M5D-20FP3-22
BK-M5D-20FP3-24
BK-M5D-18FP3-14
BK-M5D-18FP3-16
BK-M5D-18FP3-18
BK-M5D-18FP3-20
BK-M5D-18FP3-22
BK-M5D-18FP3-24
BK-M5D-16FP3-14
BK-M5D-16FP3-16
BK-M5D-16FP3-18
BK-M5D-16FP3-20
BK-M5D-16FP3-22
BK-M5D-14FP3-12
BK-M5D-14FP3-14
BK-M5D-14FP3-16
BK-M5D-14FP3-18
BK-M5D-14FP3-20
BK-M5D-12FP3-12
BK-M5D-12FP3-14
BK-M5D-12FP3-16
BK-M5D-12FP3-18
16”
18”
20”
16” 18” 20” 22”
$60100 $67700
12” 14”
14”
12”
24”
22”
$67800 $75400
16” 18” 20”12” 14” 22” 24”
FRAME WIDTH
BK-M5D-22UP3-16
BK-M5D-22UP3-18
BK-M5D-22UP3-20
BK-M5D-22UP3-22
BK-M5D-22UP3-24
BK-M5D-20UP3-14
BK-M5D-20UP3-16
BK-M5D-20UP3-18
BK-M5D-20UP3-20
BK-M5D-20UP3-22
BK-M5D-20UP3-24
BK-M5D-18UP3-14
BK-M5D-18UP3-16
BK-M5D-18UP3-18
BK-M5D-18UP3-20
BK-M5D-18UP3-22
BK-M5D-18UP3-24
BK-M5D-16UP3-14
BK-M5D-16UP3-16
BK-M5D-16UP3-18
BK-M5D-16UP3-20
BK-M5D-16UP3-22
BK-M5D-14UP3-12
BK-M5D-14UP3-14
BK-M5D-14UP3-16
BK-M5D-14UP3-18
BK-M5D-14UP3-20
BK-M5D-12UP3-12
BK-M5D-12UP3-14
BK-M5D-12UP3-16
BK-M5D-12UP3-18
16”
18”
20”
16” 18” 20” 22”
$60100 $67700
12” 14”
14”
12”
24”
22”
$67800 $75400
16” 18” 20”12” 14” 22” 24”
STRETCH AIR COMFORT TEK
5”D X 6”L WINGS
TB3-
AC
TA-B
AC
K-D
EE
P-F
OR
M R
EV
0116
BA
CK
RE
ST L
EN
GTH
BA
CK
RE
ST L
EN
GTH
BA
CK
RE
ST L
EN
GTH
BA
CK
RE
ST L
EN
GTH
*Length (L) refers to the actual size dimension of the support from bottom to top edge.
ORDER FORM 3 of 3Patient Reference:ACTA-BACK DEEP TB3 ORDER FORM
TB3-
AC
TA-B
AC
K-D
EE
P-F
OR
M R
EV
0116
BODI-LINK HEAD SUPPORT & HARDWARE3
COMFORT TEK FOR FLUID PROTECTION & AN EASILY CLEANED
SURFACE.
FOR AIR TRANSMISSION & HEAT DISSIPATION.
NOT FLUID RESISTANT.
STRETCH AIR
FOR SKIN PROTECTION & SHEAR REDUCTION. NOT FLUID RESISTANT.
L
L
L
L
L
W
W
Extra Link
Extra Spacer Plate
¼”
3.3 HEAD SUPPORT HARDWAREHCPCS CODING: E1028
MSRP $221.00/ea. MSRP $35.00/extra link or spacer each
3.2 PAD COVER MATERIAL
GlideWear® (GLIDEWEAR)
Comfort-Tek (COMFORT-TEK)
Stretch-Air (STRETCH-AIR)
Removable Hardware (BL-HSH-FX)
Extra Link (BL-HSH-LINK)
Extra Spacer Plate (BL-HSH-SPCR)
Length (L) refers to the actual size dimension of the support from bottom to top edge.
HEAD SUPPORT PAD STYLEHCPCS CODING: E0955 MSRP $230.00
3.1
3 ¼”
Pad Firmness
6W x 3½LSoft BL-HSP1-6W3L
Extra Soft BL-HSP2-6W3L
8W x 4LSoft BL-HSP1-8W4L
Extra Soft BL-HSP2-8W4L
10W x 5Lwith adjustable wings
Soft BL-HSP1-10W5L
Extra Soft BL-HSP2-10W5L
14W x 5Lwith adjustable wings
Soft BL-HSP1-14W5L
Extra Soft BL-HSP2-14W5L
18W x 5Lwith adjustable wings
Soft BL-HSP1-18W5L
Extra Soft BL-HSP2-18W5L
Patent Pending