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It specifies warnings for high-risk bone conditions during shape capture, required photos or measurements, and HIPAA-compliant handling. The form defines shape capture date, ordering/scan instructions, pricing effective January 8, 2024, and custom back options, including Medicare HCPCS E2617 and selectable AccuSoft or 3D mesh liners.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/ride-custom-back-order-form-order-form/308479/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/ride-custom-back-order-form-order-form/308479.png","ImageObject",442,249,{"name":88,"@type":89},"Cart","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-23","2026-09-20",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",10,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What information is required from the client to complete the order form?","Question",{"text":109,"@type":110},"Provide the client’s first and last name, referral and facility/clinician details, and required measurements such as trochanter landmarks, leg length, iliac crest height, axilla height, shoulder top, and outside back width.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"When is shape capture required, and what must be submitted if using RideWorks® scanning?",{"text":114,"@type":110},"Shape capture is handled through RideWorks® Scan or client measurements. If scanning is used, draw trim lines on the outer shape capture bag and submit required photos (front and side) through RideWorks files or via email with client and provider information.",{"name":116,"@type":107,"acceptedAnswer":117},"What options are available for the Ride Custom Back liners and covers?",{"text":118,"@type":110},"Select either an ultra-breathable 3D mesh liner or an AccuSoft® foam liner. With AccuSoft, the back includes a choice of spacer fabric cover or a wipeable, incontinence-proof cover, plus a specified shower-cap style for the commode back option.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},308479,1790800345,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":136,"language":137,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":138,"faqs":139,"seo_title":140,"seo_description":61,"update_tm":141,"read_time":76},18829141979164,"https://eur-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","Ride Designs®  \na branch of Aspen Seating, L LC  \ntoll-free 866.781.1633 phone 303.781.1633 fax 303.781.1722 [www.ridedesigns.com](www.ridedesigns.com)  \nRide® Custom Back Order Form  \nClient's First and Last Name*    \nAttach appropriate order form for each component ordered.  \n􀂉 Ride Custom Back (RCB200) Shape provided via:  \n􀂉 RideWorks® Scan  \n􀂉 Client measurements and finished product dimensions  \nNote: Only available with AccuSoft foam liner. See special instructions on page 4.  \nDate of shape capture:    \nAccount \\#   PO \\#   Date   SO\\#   SN\\#    \n*Internal management of personal information is HIPAA compliant.  \nGeneral Information  \nSupplier   Ride Certified Practitioner Name   Address   City   State   Zip   Phone \\#   Email   Ship to (if different from above)  \nNOTE: Ride Custom Systems must be fitted by a Ride Certified Provider and WILL NOT be drop shipped to end users.  \nAddress   City   State   Zip   Phone \\#   Email    \nReferral Source  \nFacility Name   Clinician Name   Phone \\#   Email    \nPage 1  \nContinue on page 2 © 2024, Ride Designs. 090-046-S  \nRide® Custom Back Order Form  \nClient First and Last Name    \n\n| Client Information\u003Cbr>WARNING: Caution should be exercised when capturing shapes in Ride Simulators for people\u003Cbr>with osteoporosis, bone cancer, history of pathological fracture, osteogenesis imperfecta, or any brittle bone condition.\u003Cbr>Sex: 􀂉 M 􀂉 F Diagnosis  \u003Cbr>Does client have:\u003Cbr>􀂉 Current tissue injury? Location  Stage  \u003Cbr>􀂉 History of tissue injury? Location   Stage   Height   Weight   |  |\n| --- | --- |\n| Client Measurements\u003Cbr>A. Trochanters   \"\u003Cbr>B. Leg length L   \" R   \"\u003Cbr>C. Iliac Crest   \"\u003Cbr>D. Mid-Thorax   \"\u003Cbr>E. Axilla   \"\u003Cbr>F. A-P Mid-Thorax   \" | G. Top of Iliac Crest L  \" R  \"\u003Cbr>H. Axilla height L  \" R  \"\u003Cbr>I. Top of shoulder L  \" R  \"\u003Cbr>J. Knee to heel   \"\u003Cbr>K. Top of head   \"\u003Cbr>L. A-P abdomen   \" |\n| Mobility Base Specifications\u003Cbr>Wheelchair Make   Model   Frame Width   \" Depth   \" |  |\n\nPage 2  \n© 2024, Ride Designs. 090-046-S [Patents: www.ridedesigns.com/patents](Patents: www.ridedesigns.com/patents)  \nRide® Custom Back Order Form  \nClient First and Last Name    \nPrices effective January 8, 2024.  \nShape capture method  \n▲  \nUsing RideWorks® app?  \nBefore scanning, on the clear, outer shape capture bag (using a black permanent marker), draw trim lines and marks to draw the back as it should be manufactured, including:  \n􀂉 Arrow pointing upward, indicating top of back  \n􀂉 Soft relief areas to protect bony prominences  \n􀂉 Depth and height of the lateral trunk supports  \nBefore transferring client from shape capture bag, please complete the following…  \nPHOTOS of client in shape capture bag: 􀂉 Front view 􀂉 Side view  \n􀂉 Included in RideWorks® client files  \n􀂉 Emailed to [customerservice@ridedesigns.com](customerservice@ridedesigns.com), with client name and provider information  \n􀂉 Attached  \nTrim lines; establish and mark on clear, outer shape capture bag:  \n􀂉 Back height 􀂉 Lateral support depth and height 􀂉 Iliac crest height  \nDID YOU SEND  \nPHOTOS?  \nPage 3  \n* All prices are in U.S. dollars.  \nContinue on page 4  \n© 2024, Ride Designs. 090-046-S [Patents: www.ridedesigns.com/patents](Patents: www.ridedesigns.com/patents)  \nRide® Custom Back Order Form  \nClient First and Last Name   Ordering with no scan-just client measurements and finished product dimensions. (Skip to pg 5 if submitting a scan.)⚠Ifrmportanom a captured:haCplieetshatwihsoscpresenannedtawitndhssuignibmiceadnttopoRstuideral asymmetries and require substantial support to maintain optimal posture will experience the best outcome with a Ride Custom Back made  \nStep 1-Client Measurements  \nMake sure the following client measurements are provided, either on page 2, or here:  \nG. Top of Iliac Crest L  \" R  \"  \nH. Axilla Height L  \" R  \"  \nI. Top of Shoulder L  \" R  \"  \nStep 2-Desired finished back height   \"  \nStep 3-Desired finished lateral height from seat to top of lateral. (For full-height lateral pa","cbCaiimbuVGYLp6f","https://ap.wps.com/l/cbCaiimbuVGYLp6f","pdf",1513612,9,"English","# General Information\n## Client Information\n## Shape Capture Method\n## Ordering Without a Scan (Measurements Only)\n## Ride Custom Back Type\n## Ride Custom Back Size","[{\"question\":\"What information is required from the client to complete the order form?\",\"answer\":\"Provide the client’s first and last name, referral and facility/clinician details, and required measurements such as trochanter landmarks, leg length, iliac crest height, axilla height, shoulder top, and outside back width.\"},{\"question\":\"When is shape capture required, and what must be submitted if using RideWorks® scanning?\",\"answer\":\"Shape capture is handled through RideWorks® Scan or client measurements. If scanning is used, draw trim lines on the outer shape capture bag and submit required photos (front and side) through RideWorks files or via email with client and provider information.\"},{\"question\":\"What options are available for the Ride Custom Back liners and covers?\",\"answer\":\"Select either an ultra-breathable 3D mesh liner or an AccuSoft® foam liner. With AccuSoft, the back includes a choice of spacer fabric cover or a wipeable, incontinence-proof cover, plus a specified shower-cap style for the commode back option.\"}]","Ride® Custom Back Order Form - Order Form | PDF",1789869181]