Page 1 of 18 INFINFB4179/RevB/22JAN2020 Q6 Edge ® 3 Stretto Order Form with TRU-Balance ® 3 Positioning Quantum ® Rehab 401 York Ave., Duryea, PA 18642 Phone: 866-800-2002 | Fax: 866-707-3422 | Email: [email protected]Account Number: ___________ Date: ________________ Provider Name: __________________________________ Contact: ________________________________________ Phone: ___________________ Fax: _________________ Email:__________________________________________ PO Number:_____________________________________ Marked for: _____________________________________ Ship to Address: _________________________________ City: _____________________ State: ______ Zip: ______ Weight:________ Height:________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ A. Shoulder Width:_______ B. Chest Width: _________ C. Hip Width: ___________ D. Max Sitting Height: ____ E. Shoulder Height: ______ F. Axilla Height: _________ G. Thigh Depth: _________ H. Lower Leg Length: ____ I. Elbow Height: ________ This form is interactive when viewed with Adobe Acrobat Reader and may not function correctly if opened with applications other than Acrobat. Com- plete the form by placing checks in the desired boxes and provide information in the interactive fields. Buttons shown at the bottom of the form may be utilized to print or submit the order form through a desktop email application. To email via a web-based application, please ‘Save As’ and attach the PDF to your email. This order form contains a large variety of options to fulfill various patient needs. Descriptions and section notes, such as optional or required, are included to help you complete your order. Please contact Quantum Sales at 866-800-2002 if assistance is needed. Send the completed order form by fax (866-707-3422) or email ([email protected]). Incomplete forms may delay the quote or order. Customer service will contact you if the order is incomplete or if there are compatibility issues. If special order requests are needed, be sure that the Patient Information section is completed or include a completed physical assessment form with this order form. HCPCS codes provided should not be considered as legal advice and do not guarantee reimbursement. DME providers are responsible for deter- mining the appropriate billing codes when submitting for insurance reimbursement. Payer coding, coverage, and bundling guidelines may apply. All prices are MSRP. Prices, specifications, part numbers, and availability are subject to change without notice. Prices and part numbers as shown are only available when configured as a complete power chair. Please contact technical service for accurate parts ordering. Options noted with "XRef" have multiple possible part numbers based on system configuration. Please see cross-reference spreadsheet for the XRef part numbers. Thank you for choosing Quantum! INTRODUCTION PATIENT INFORMATION 1. BASE MODEL REQUIRED. Select a group 3 power base. 300 lb. weight capacity with standard 6mph programmable motors and off board charger. XLR USB charger is included. Dimensions of base without legrests: 20.5”Wx35.5”L Quantum Q6 Edge 3 Stretto 3S-SS................................... $7,895 Part: Q6 EDGE 3 STRETTO 3S-SS. HCPCS: K0848 Solid seat pan standard with no power option. Quantum Q6 Edge 3 Stretto 3SP-SS ................................. $7,895 Part: Q6 EDGE 3 STRETTO 3SP-SS. HCPCS: K0856 Single power option. Quantum Q6 Edge 3 Stretto 3MP-SS ................................ $7,895 Part: Q6 EDGE 3 STRETTO 3MP-SS. HCPCS: K0861 Multiple power option.
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Page 1 of 18INFINFB4179/RevB/22JAN2020
Q6 Edge® 3 Stretto Order Form with TRU-Balance® 3 Positioning
Quantum® Rehab401 York Ave., Duryea, PA 18642Phone: 866-800-2002 | Fax: 866-707-3422 | Email: [email protected]
A. Shoulder Width: _______B. Chest Width: _________C. Hip Width: ___________
D. Max Sitting Height: ____E. Shoulder Height: ______F. Axilla Height: _________
G. Thigh Depth: _________H. Lower Leg Length: ____I. Elbow Height: ________
This form is interactive when viewed with Adobe Acrobat Reader and may not function correctly if opened with applications other than Acrobat. Com-plete the form by placing checks in the desired boxes and provide information in the interactive fields. Buttons shown at the bottom of the form may be utilized to print or submit the order form through a desktop email application. To email via a web-based application, please ‘Save As’ and attach the PDF to your email.
This order form contains a large variety of options to fulfill various patient needs. Descriptions and section notes, such as optional or required, are included to help you complete your order. Please contact Quantum Sales at 866-800-2002 if assistance is needed. Send the completed order form by fax (866-707-3422) or email ([email protected]). Incomplete forms may delay the quote or order. Customer service will contact you if the order is incomplete or if there are compatibility issues. If special order requests are needed, be sure that the Patient Information section is completed or include a completed physical assessment form with this order form.
HCPCS codes provided should not be considered as legal advice and do not guarantee reimbursement. DME providers are responsible for deter-mining the appropriate billing codes when submitting for insurance reimbursement. Payer coding, coverage, and bundling guidelines may apply. All prices are MSRP. Prices, specifications, part numbers, and availability are subject to change without notice. Prices and part numbers as shown are only available when configured as a complete power chair. Please contact technical service for accurate parts ordering. Options noted with "XRef" have multiple possible part numbers based on system configuration. Please see cross-reference spreadsheet for the XRef part numbers.
Thank you for choosing Quantum!
INTRODUCTION
PATIENT INFORMATION
1. BASE MODELREQUIRED. Select a group 3 power base. 300 lb. weight capacity with standard 6mph programmable motors and off board charger. XLR USB charger is included. Dimensions of base without legrests: 20.5”Wx35.5”L
Quantum Q6 Edge 3 Stretto 3S-SS ................................... $7,895Part: Q6 EDGE 3 STRETTO 3S-SS. HCPCS: K0848Solid seat pan standard with no power option.
5. BATTERIESREQUIRED. The powerchair requires 2 batteries and will be installed if ordered.
4. FULL LIGHT PACKAGEOptional. Requires NE+ 8 Key or Q-Logic 3 Joystick for Full Light Package.
3. FENDER LIGHTSOptional. Fender lights operate by pressing included single switch button. Fender lighting is not available with Single Actuator Control through Toggle Box.
Full Light Package..........................................................................................................................................................$995Part: ELE1905403
Match All Color Options to Selection BelowPart: N/A. Any subsequent color selections, if available, will be matched to color chosen below when the order is placed. Please note that some color selections, such as joystick armor, may have a MSRP.
2.1. Match Colors
Back in Black .........................No ChargePart: DGN164245-PBK1 x2
Red Corvette .........................No ChargePart: DGN164245-PRD1 x2
6.2. Drive Wheel Accent Color for 14" TiresNot available with 12.5" tires.
6. DRIVE WHEELSREQUIRED. Select a type of drive wheel. Accent colors are available for 14" tires.
6.1. Drive Wheels2”x12.5” Pneumatic Tires ....................................... No ChargePart: WHL1810666
2”x12.5” Flat Free Tires ......................................... No ChargePart: WHL1810665
3”x14” Pneumatic Tires .......................................... No ChargePart: WHL1713925
3”x14” Flat Free Tires ............................................ No ChargePart: WHL1704058
Page 3 of 18INFINFB4179/RevB/22JAN2020
NE+ 6 Key Joystick
NE 4-Key Joystick ....................................StandardPart: CTLDC1554Available with Tilt Only through Toggle.
NE+ 6-Key Joystick (1 Actuator) ................No ChargePart: CTLDC1560Control of one actuator through Joystick on single power base model (3SP-SS) only.
NE+ 6-Key Joystick (2 Actuators) .....................$200Part: CTLDC1560Control up to 2 actuators through joystick.
NE+ 8-Key Joystick (2 Actuators) .....................$400Part: CTLDC1561Control up to 2 actuators through joystick and full light package.
No Joystick, Setup for NE+ Joystick ...........No ChargePart: Configuration selection
7.1a. Non-Expandable ControlsSelect a joystick below or omit selection if another controller type is desired. Non-expandable does not allow supplementary drive controllers.
1. Q-Logic 3 Required ComponentsQ-Logic 3 expandable controls require the controller module and expandable harness below. If a Q-Logic joystick or specialty control is selected, Customer Service will quote the order with these items.
2. Q-Logic 3 Joystick
7.1b. Expandable Controls - Quantum Intelligent Systems™Select expandable controls or omit selection if another controller type is desired. Expandable controls allow multiple or specialized controllers.
Q-Logic 3 EX Controller Module .......................$695Part: See XRef. HCPCS: E2377
Q-Logic 3 EX Joystick ....................................$700Part: CTL167724
No Joystick, Setup for Q-LogicPart: Configuration selection.
Q-Logic 3 EX Joystick for Full Lights .................$700Part: CTL167725
Q-Logic 3 EX Joystick
Black, Soft Touch ................. StandardPart: DGN124307Also matches Night Train shrouds.
Non-matching Armor ....................$50Part: PTOINDV3422Select color below.
Match Armor to Base Color ............$50Part: PTOINDV3421
7.2. Q-Logic 3 Joystick ArmorREQUIRED with Q-Logic 3 Joystick selections above. Reference colors shown on page 2. *Night train joystick armor will be the black, soft touch.
7. ELECTRONICSREQUIRED. Select a type of drive control from the following sections. The No Joystick option is used to omit the joystick and utilize another control, such as a specialty control at the end of this form or found on the Alternative Controls and Electronics Order Form.
8. JOYSTICK HANDLESOptional. The NE/NE Plus Joysticks are standard with a carrot handle (See A in image). The optional handle will be mounted to the joystick and the standard handle will be shipped with the unit.
To determine if your chair is WC-19 compliant (occupied), please re-fer to this website: http://wc-transportation-safety.umtri.umich.edu/crash-tested-product-lists/wheelchairs
10.3. Occupied Transit KitOptional. The power base is standard with Unoccupied Transit Loops. 60” Sure-Lok Lap Belt is required with Occupied Transit Option.
9.1b. Swing-Away (Retractable) Joystick BracketAllows the joystick to retract to the side of the armrest while maintaining the same joystick orientation. "Inline bracket" is used with TRU-Balance 3 arms when the joystick is inline with armpad. "Inline bracket" will be offset 1" when used with tube style arms. Select "Offset Bracket" to have the joystick inline with armpad on tube style armrests.
9.1c. Specialty Joystick MountsSelect a bracket and side to mount it.
Specialty Mount Side
9.1a. Fixed, In-line Joystick Bracket
9. JOYSTICK MOUNTING BRACKETSOptional. Select a mount to be used with a joystick selected in previous section.
Omit Joystick Mounting Bracket
Swing-away, Inline, Left Side Mount ..................$245NE/NE+ Part: ACC142526. Q-Logic: ACC142524. HCPCS: E1028
Swing-away, Inline, Right Side Mount ................$245NE/NE+ Part: ACC142527. Q-Logic: ACC142525. HCPCS: E1028
Swing-away, 1” Offset, Left Side Mount .............$245NE/NE+ Part: ACC142747. Q-Logic: ACC142742. HCPCS: E1028
Swing-away, 1” Offset, Right Side Mount ............$245NE/NE+ Part: ACC142748. Q-Logic: ACC142743. HCPCS: E1028
Retract4 Mount ............................................$350NE/NE+ Part: MEC138876. HCPCS: E1028Q-Logic Part: MEC138860. HCPCS: E1028Full 180° of movement that translates into multi-position use, straight, right offset, left offset, or fold away. Joy-stick orientation varies as bracket is adjusted.
Multi-Axis Mount ..........................................$100NE/NE+ Part: ACC142528. HCPCS: E1028Q-Logic Part: ACC131216. HCPCS: E1028SAJ Part: ACC142740. HCPCS: E1028Allows height adjustment of joystick.
Stealth Swing-Away/Flip Down Bracket ..........$294.25NE/NE+ Part: ST-TWBM480QL-Q. HCPCS: E1028Q-Logic Part: ST-TWBM480QL-Q. HCPCS: E1028SAJ Part: ST-TWBM480CJ-Q. HCPCS: E1028Allows the joystick to pivot to side of armrest,or flip-down if bracket is adjusted.
10.1. TRU-Balance 3 ConfigurationTRU-Balance 3 Static Seat ............................................$2,295Part: PTOINDV344220° of limited recline adjustment (-5/ +15) via gas strut within back cover.
TRU-Balance 3 Power Tilt Only ......................................$6,995Part: PTOINDV3443. HCPCS: E100250° Center of Gravity (CG) power tilt seating system.
TRU-Balance 3 Power Recline Only ................................. $7,595Part: PTOINDV3444. HCPCS: E1004175° of power recline.
TRU-Balance 3 Power Tilt & Recline ...............................$11,895Part: PTOINDV3446. HCPCS: E100750° CG power tilt with 175° of power recline. Full drive lockout at 20°.
TRU-Balance 3 12” Power Lift with iLevel® ..................................................................................... $2,600Part: PTOINDV3773. HCPCS: E230012” of scissor lift with iLevel System.
10.2. 12" Power LiftOptional.
TRU-Balance 3 Seating section continued on following pages.
10.4. Seat Dimension - WidthREQUIRED with seat selection. Maximum seat width is 20". Part number is SETWDTH plus number following # below. 12” Width is not available with 16” and 17” Depth. 13” and 15” widths are only available with non-matching back width.
10.5. Seat Dimension - Width PackageREQUIRED with seat selection. Width and depth package part: See XRef: TB3SPACK
10.7. Seat Dimension - Depth PackageREQUIRED with seat selection. Width and depth package part: See XRef: TB3SPACK
10.9. Seat CushionOptional. Specific cushion/component sizes available, part numbers, weight capacities, and special order cushions can be found on the respective complete Stealth Cushion Order Forms. This section allows a quick selection of a single cushion. The XXYY portion of the part number directly relates to the dimensions of the cushion, where XX represents the width and YY represents the depth. 1. Seat Cushion Model Selection
TRU-Balance 3 Seating section continued on following pages.
10. TRU-BALANCE 3 SEATING continued
Lowest Seat to FloorPart: PTOINDV3558
Middle Seat to FloorPart: PTOINDV3559
Highest Seat to FloorPart: PTOINDV3560
TRU-Comfort 2 SPP, 16"W to 20" W, E2607 .........$400Simplicity G, 12"W to 20" W, E2601 .................. $110
Solution SPP, 12"W to 21" W, E2607 ..................$375
Spectrum Gel SPP, 14"W to 20" W, E2607 ...........$460Spectrum Foam SPP, 16"W to 20" W, E2607 ........$460
Stealth Simplicity G CushionGeneral use cushion with Stealth Tek 2, 2-way stretch, breathable cover.Part series: ST-SIMGXXYY
Stealth Solution SPP CushionSkin protection and positioning with Coolcore, 4-way stretch, breathable cover. Includes urethane liner.Part series: ST-SOLSPPXXYY
Stealth Spectrum Gel SPP CushionSkin protection and positioning with Coolcore, 4-way stretch, breathable cover. Includes urethane liner.Part series: ST-SPCGSPPXXYY
Stealth TRU-Comfort 2 SPP CushionSkin protection and positioning with Coolcore, 4-way stretch, breathable cover.Part series: ST-TC2SPPXXYY
Stealth Spectrum Foam SPP CushionSkin protection and positioning with Coolcore, 4-way stretch, breathable cover. Includes urethane liner.Part series: ST-SPCFSPPXXYY
Glacial SP, 12"W to 21"W, E2603 .......................$330
Premiere P, 16"W to 20" W, E2605 ....................$325
Stealth Premiere P CushionPositioning with Coolcore, 4-way stretch, breathable cover.Part series: ST-PREMPXXYY
Stealth Essence SPP CushionSkin protection and positioning with Coolcore, 4-way stretch, breathable cover.Part series: ST-ESSSPPXXYY
Zen SP, 12"W to 21" W, E2603 .......................... $315
Stealth Zen SP CushionSkin protection with Coolcore, 4-way stretch, breathable cover.Part series: ST-ZENSPXXYY
Essence SPP, No Wedge, 16"-20" Wide, E2607 ........$400Essence SPP, Small Wedge, 16"-20" Wide, E2607 .... $435Essence SPP, Medium Wedge, 16"-20" Wide, E2607 . $465Essence SPP, Large Wedge, 16"-20" Wide, E2607 .... $495
Fluid Proof Urethane Liner ........................................$50-$70*Part: URL1709070-XXYYNot available with Simplicity or TRU-Comfort 2.
Fluid Proof Polyurethane Liner ................................... $55-$75*Part: PUL1709030-XXYYNot available with Simplicity.
Match Seat Width and Depth
12” W14” W
15” W16" W
17" W18" W
19" W20" W
12" D14” D
15” D16" D
17" D18" D
19" D20" D
Cushion Width Cushion Depth
2. Seat Cushion DimensionsREQUIRED with cushion model selection. Select to match or pick non-matching dimensions. See respective cushion order form for available sizes.
3. Seat Cushion Alternate/Add Fluid Proof LinersA liner may be added or the standard liner may be substituted with a selection below. *A substitution credit may apply. See the respective cushion order form for more details.
Stealth Tek 2 Cover ...................................................... $100*Part: *prefix-TBLKXXYYNot available with Simplicity or TRU-Comfort 2.
Mesh Cover ................................................................ $100*Part: *prefix-MBLKXXYYNot available with Simplicity or TRU-Comfort 2.
4. Seat Cushion Alternate/Additional CoverAn additional cover may be ordered or the standard cover may be substituted with a selection below. *A substitution credit may apply, see the respective cushion order form for more details. The "*prefix" of the part number will be the part prefix of the cushion model selected above. For example, SPCGSPP-NBLK1816 will be an additional coolcore cover for a Spectrum Gel cushion.
10.10. Back Type SelectionREQUIRED. Match a choice in this section with the options in the following back cushion configuration section.
Redesigned, Static Type BackPart: Configuration selection12" and 24" back width will use the TRU-Balance 3 Back assembly. Select a back cushion configuration in the subsequent section.
Back Cane OptionPart: Configuration selectionAvailable only with TRU-Balance 3 Static Seat and Power Tilt (1 actua-tor) selections. Select cane type, back cane height, and back cushion configuration below. Widths less than 15" must select Omit Back Pan/Cushion.
Redesigned, Flip Forward Back ........................................ $150Part: See XRef12" and 24" back width will use the TRU-Balance 3 Back assembly. Available with TRU-Balance 3 Static Seat and Power Tilt (1 actuator). Only available with 2-post, flip back, or pediatric armrests. Not avail-able with 12”-14” width. Select a back cushion type in the subsequent section.
10.11. Back Cane Selection (Back Cane Option Only)REQUIRED when Back Cane Option is selected above. Select type and height of back canes.
2. Back Cane Height
1. Back Cane TypeAngle Adjustable ................................................... No ChargePart: MEC140266
10.12. Back Cushion Configuration - TypeREQUIRED. Sport Back and TRU-Comfort Back selections up to 22" back width will be the Sport 4 or TRU-Comfort 4 back cushions. Sport back and TRU-Comfort back selections of 24" back width will be the Sport or TRU-Comfort 2 back cushions. Select a configuration type and applicable dimensions. See the Sport, Q-Back, and TRU-Comfort back availability chart for stock order back size ranges. Other size backs may be available with special order and extended lead time.
Sport Back ........................................................... No ChargePart: See XRefComplete following width package and size.
ADI Q-Back, Active Contour ............................................ $525Part: See XRef. HCPCS: E2613Complete following width package and size.
ADI Q-Back, Deep Contour .............................................. $595Part: See XRef. HCPCS: E2615Complete following width package and size.
ADI Q-Back, Extra Deep Contour ...................................... $650Part: See XRef. HCPCS: E2620Complete following width package and size. 20" Wide Extra Deep Contour is not compatible with Gel and Water-fall Armpads, Endo/Meso Downposts, 2 Post Arms, or Ottobock arm blocks unless wider arm bars are installed on the chair.
TRU-Comfort Back, 20” Width or less ................................ $675Part: See XRef. HCPCS: E2620Complete following width package and size.
TRU-Comfort Back, 22” Width or greater ........................... $775Part: See XRef. HCPCS: E2621Complete following width package and size.
Omit Back Pan/Cushion ........................................... No ChargePart: PTOINDV1287Select a following width package.
After-market Back Interface ........................................... $200Part 16"-20"W: SET131920. Part 20"-24"W: SET131921Select a set width in following section, range of 16"-24". Overall seat depth may need to be adjusted to accommodate certain backs. May interfere with gel/waterfall armpads and arm through. Does not in-clude brackets to mount after-market backs. A Special Order is re-quired on back widths less than 16”.
TRU-Balance 3 Seating section continued on following page.
10. TRU-BALANCE 3 SEATING continued
10.13. TRU-Balance 3 Back ShroudREQUIRED. The back shroud is a feature of the TRU-Balance 3 seating system and is available in matching shroud colors. The back shroud is not available when Omit Back Pan/Cushion is selected. Reference colors shown on page 2.
Red CorvetteRedesign part: DGN1714085-PRD1TB3 Back/Back cane part: DGN148034
10.15. Back Width PackageREQUIRED except when Omit Back Pan/Cushion is selected. Available with +/-4” of seat width.
Match Seat Width SelectionsPart: PTOINDV3468
10”W-14”W PackagePart: Configuration selection
14”W-16”W PackagePart: Configuration selection
16”W-20”W PackagePart: Configuration selection
18”W-22”W PackagePart: Configuration selection
20”W-24”W PackagePart: Configuration selection
10.16. Back Cushion Configuration - Back WidthREQUIRED except when Omit Back Pan/Cushion is selected. Part number is PTOINDV plus number following # below. Available with +/-4” of seat width.
12” W(#3562)
14” W(#3563)
16” W(#3564)
17” W(#3565)
18” W(#3566)
19” W(#3567)
20” W(#3568)
21” W(#3569)
22” W(#3570)
24” W(#3571)
10.18. Power Tilt Privacy FlapOptional. A privacy flap is standard with power recline systems. This selection is to add a flap for power tilt only systems.
10.19. Back Height ExtensionOptional. Not available with back cane option, 12" back width, or 24" back width. Adds 2" of seat back pan height. 25"H selection includes a back height extension.
Back Height Extension ................................................................................................................................................. $44.9514"-16" back width part: MEC1906115. 16"-20" back width part: MEC1906116. 18"-22" back width part: MEC1906117
TRU-Balance 3 Armrest section continued on following page.
10. TRU-BALANCE 3 SEATING continued
14” HeightPart: SETHGHT1027
15” HeightPart: SETHGHT1028
16” HeightPart: SETHGHT1029
17” HeightPart: SETHGHT1030
18” HeightPart: SETHGHT1031
19” HeightPart: SETHGHT1032
20” HeightPart: SETHGHT1033
21” HeightPart: SETHGHT1034
22” HeightPart: SETHGHT1035
23” HeightPart: SETHGHT1036
24” HeightPart: SETHGHT1037
25” HeightPart: SETHGHT1038
26” HeightPart: SETHGHT1039
27” HeightPart: SETHGHT1040
28” HeightPart: SETHGHT1041
10.17. Back Cushion Configuration - Overall Back HeightStatic Seat and Power Tilt available height range: 14”-25”H. Odd heights include 4” gap and even heights include 3” gap between seat pan and bottom of back cushion. Power Recline available height range: 19”-28”H. Odd heights include 6” gap and even heights include 7” gap. See the Sport and TRU-Comfort back availability chart for stock order back size ranges.
11. TRU-BALANCE 3 ARMRESTSREQUIRED. Select the desired type of armrest below. Please read notes to ensure seating compatibility. Be sure to also select an armrest size and armpad type.
Flip-Back, 8"-16"H Armrests .................................................................................................................................. StandardLeft part: ARM1806662. Right part: ARM1806663
11.1a. Flip-Back, 8"-16" H ArmrestsChoose a left and right armrest and set height in the following section. Not available with waterfall armpads. Not available with Back Cane Option.
10.14. Lateral Positioning WedgeOptional.
Lateral Positioning Wedge, pair ......................................................................................................................................... $30Part: SET123465Available with Sport and TRU-Comfort backs. Not available on power tilt backs 16”-17”H with limited adjustability on 18” H. Not available on power recline back 19”-20”H with limited adjustability on 21”H.
Tilt or Static Width Recline Width
Sport, Q-Back, and TRU-Comfort Back Availability Chart
Ove
rall
Hei
ght
Sport or TRU-Comfort BackSport BackSport, Q-Back, or TRU-Comfort BackTRU-Comfort Back
Page 8 of 18INFINFB4179/RevB/22JAN2020
11.2. Armrest HeightREQUIRED. Set left and right armrest height. Note the available height range in the option description.
8” HPTOINDV3535
9” HPTOINDV3536
10” HPTOINDV3537
11” HPTOINDV3538
12” HPTOINDV3539
13” HPTOINDV3540
14” HPTOINDV3541
15” HPTOINDV3542
16” HPTOINDV3543
8” HPTOINDV3450
9” HPTOINDV3451
10” HPTOINDV3452
11” HPTOINDV3453
12” HPTOINDV3454
13” HPTOINDV3455
14” HPTOINDV3456
15” HPTOINDV3457
16” HPTOINDV3458
1. Left Armrest Height
2. Right Armrest Height
11.3. Armrest SizeREQUIRED. Select a left (L) and right (R) armrest size. This also affects armpad selection.
10” LengthPart: Configuration selection
14” LengthPart: Configuration selection
17” LengthPart: Configuration selectionOnly available with Flip-Back, 8"-16" H Armrests and straight arm pads.
2-Post, Flip Back, Height Adjustable, and Removable Armrests (9”-13” Height) .................................................... $150 ea. or No Charge*Part: See XRef. HCPCS: E0973Not available with a depth less than 16”. Required with flip forward back and lap trays. *No charge with power seating.
8”-12”H, Single Post, Height Adjustable, Removable, .........$75 ea.Heavy Duty (Sold in pairs)Part: See XRef. HCPCS w/ Static Seat: E0973
10”-14”H, Single Post, Height Adjustable, Removable,........$75 ea.Heavy Duty (Sold in pairs)Part: See XRef. HCPCS w/ Static Seat: E0973
11.1c. Two-Post ArmrestsSelect the armrest and set the left and right heights in the following section. These armrests may interfere with offset backs/ back canes.
11.1d. Heavy Duty, Removable ArmrestsSelect a type of HD removable armrests and the set height in the following section. Only one height package is selectable as a normal configuration. Payer coding, coverage, and bundling guidelines may apply.
TRU-Balance 3 Armrest for Downpost, 8”-12”H ........ No ChargePart: See XRefMust select downpost below.
TRU-Balance 3 Armrest for Downpost, 12”-16”H ...... No ChargePart: See XRefMust select downpost below.
TRU-Balance 3 Armrest Downpost (Pair) ...................................................................................................................... $87.50 ea.Part: See XRefAvailable up to 2” difference between seat and back width via endomorph or mesomorph configuration. Not available on 14” Width seat or back.
11.1b. TRU-Balance 3 Armrests with DownpostChoose a left and right TRU-Balance 3, flip-back armrest, downpost, and set height in the following section. Different left (L) and right (R) armrest height packages are allowed. Not available with Back Cane Option. Not available with 17" length arm size.
TRU-Balance 3 Armrest SupportRequired with TRU-Balance 3 Armrest for Downpost selection above.
Falcon Gel, Full Length Left and Right ........................... $296.40Part: ARM136438
Falcon Gel, Full Length Left, Desk Length Right ............... $274.22Part: ARM136442
Falcon Gel, Desk Length Left, Full Length Right ............... $274.22Part: ARM136439
Falcon Gel, Desk Length Left and Right ......................... $252.40Part: ARM136437
Falcon Gel, Full Length Left and Right ............................... $185Part: ARM136417
Falcon Gel, Full Length Left, Desk Length Right ............... $162.50Part: ARM136426
Falcon Gel, Desk Length Left, Full Length Right ............... $162.50Part: ARM136418
Falcon Gel, Desk Length Left and Right ............................. $140Part: ARM136416
12.1b. Gel ArmpadsSold only in pairs. Armpads are 3” wide. Manufacturer part number for full length is 314G and desk length is 310G.a. Falcon Gel Armpads for TRU-Balance 3 Flip-Back Armrests
b. Falcon Gel Armpads for Tube Style Armrests
12. TRU-BALANCE 3 ARMPADSREQUIRED. Select to omit an armpad selection or select a left and right armpad type. Please note that waterfall and gel armpads may cause interference with the seat back.
12.1a. Foam Armpads
No Armpad Selection and/or See Positioning Components Page or Order Form .....................................................................No ChargePart: Configuration selection
Straight, Armpad ................................................ StandardPart: See XRef
Waterfall, Armpad ............................................ No ChargePart: See XRefNot available with Flip-back, 8"-16" armrests.
Standard Fixed Receiver ...........................StandardPart: ACC123525Flip-back, 8"-16" part: ACC1806853
Stealth Height Adjustable Receiver ................... $214Tube arm part: ST-ARM250C-Q. HCPCS: K0108TRU-Balance 3 arm part: ST-ARM250T-Q. HCPCS: K0108
Flip-Back Armrest, Side Track Accessory Bracket ..................................................................................$10Part: MEC1809178
Height AdjustableReceiver (Tube Style)
13.1. Joystick BracketREQUIRED.
13.2. Side Track Accessory Bracket for Flip-Back ArmrestsOptional. Only available with flip-back, 8"-16" H armrests. This adds a 47mm channel to the side of the armrest to allow mounting of accessories with t-nuts.
14. TRU-BALANCE 3 HEADRESTSOptional. Select a headrest pad and bracket.
Headrests
38” Lap BeltPart: ACCBELT1006
50” Lap BeltPart: ACCBELT1000
60” Lap BeltPart: ACCBELT1002
70” Lap BeltPart: ACCBELT1003
80” Lap BeltPart: ACCBELT1004
90” Lap BeltPart: ACCBELT1001
15. LAP BELTSREQUIRED. Select a lap belt below.15.1a. Standard Lap Belts
15.1b. Optional Lap BeltsStealth Retractable Lap Belt (IFRB5350) ..............................$175Part: ST-IFRB5350
i-Fit 60” Single Pull, Push Button, Medium ...........................$86(7.5”) Padded, 1.5” Belt (IFPB5213)Part: ST-IFPB5213-Q
i-Fit 60” Single Pull, Push Button, Large ..............................$86Padded (9.5”), 2” Belt (IFPB5314)Part: ST-IFPB5314-Q
i-Fit 60” Single Pull, Push Button, Extra Large ......................$86Padded (11.5”), 2” Belt (IFPB5315)Part: ST-IFPB5315-Q
60” Sure-Lok Lap Belt (Non-retractable) ............................ $120Required with ISO 7176-19 Compliant Transit Option.Part: ACCBELT1016
16. TRU-BALANCE 3 LEGREST CONTROLSOptional. Specific power legrest options are selected later in this form. Select the control type here, if power legrests are desired, to assist the selection of the power positioning electronics.
Independent Legrests (adds 2 actuator control requirement)Part: Configuration selection
Combined Legrests (adds 2 actuator control requirement)Part: Configuration selection
Articulating Foot Platform (adds 1 actuator control requirement)Part: Configuration selection
17.1b. NE+ 6 Key Controls through JoystickSingle Actuator Control Through NE+ Joystick ...$1,895Part: See XRef. HCPCS: E2310
Two Actuator Control Through NE+ Joystick .... $2,895Part: See XRef. HCPCS: E2311
Single Actuator Control, Power Tilt Only, Through Toggle (NE 4-Key Joystick Only) ................................................................No ChargePart: ELE1905907Select toggle side. May require extended lead time when selected with Fender Lights.
Left Side Toggle Right Side TogglePart: PTOINDV1839 Part: PTOINDV1838
Single Actuator Through Q-Logic 3 .................$1,895Controller and Interface (AM1)Part: See XRef. HCPCS: E2310
Single Actuator Through Q-Logic 3 ................ $2,895Controller and Interface (AAM)Part: See XRef. HCPCS: E2310
Multiple Actuator Through Q-Logic 3.............. $2,895Controller and Interface (AAM)Part: See XRef. HCPCS: E2311
17.1c. Q-Logic 3 Controls through Joystick
4 Way Toggle 4 Way Button TogglePart: ELEASMB5925 Part: ELEASMB5926
Optional Switch ControlNot available with AM1 electronics. Switch will be mounted to same side of joystick.
Switch Controls
4 Way Toggle
4 Way ButtonToggle
4 FunctionPush Button
iAccessFlat Button
iAccessToggle Button
17.1e. Q-Logic 3 Controls with 4 Function Push ButtonSingle Actuator Control Through 4 Function .....................$2,895Push Button and Q-Logic 3 Controller and Interface (AAM)Only available with TB3 armrests. Select a side to mount. Part: See XRef. HCPCS: E2310
Multiple Actuator Control Through 4 Function ...................$2,895Push Button and Q-Logic 3 Controller and Interface (AAM)Only available with TB3 armrests. Select a side to mount. Part: See XRef. HCPCS: E2311
Left Side Mount Right Side MountPart: PTOINDV3678 Part: PTOINDV3679
4 Function Push Button Mount Location
Left Side iAccess Right Side iAccessPart PTOINDV3678 Part: PTOINDV3679
Single Actuator Control, Through Flat Button ....................$2,295iAccess and Q-Logic 3 Controller and Interface (AM1)Part: See XRef. HCPCS: E2310
Single Actuator Control, Through Flat Button ....................$3,295iAccess and Q-Logic 3 Controller and Interface (AAM)Part: See XRef. HCPCS: E2310
Multiple Actuator Control Through Flat Button ..................$3,295iAccess and Q-Logic 3 Controller and Interface (AAM)Part: See XRef. HCPCS: E2311
Single Actuator Control, Through Toggle Button ................$2,295iAccess and Q-Logic 3 Controller and Interface (AM1)Part: See XRef. HCPCS: E2310
Single Actuator Control, Through Toggle Button ................$3,295iAccess and Q-Logic 3 Controller and Interface (AAM)Part: See XRef. HCPCS: E2310
Multiple Actuator Control Through Toggle Button ...............$3,295iAccess and Q-Logic 3 Controller and Interface (AAM)Part: See XRef. HCPCS: E2311
17.1d. Q-Logic 3 Controls with iAccess Switch ControliAccess control is not available with combined or independent power legrests.
iAccess Mount Location
18. TRU-BALANCE 3 ATTENDANT CONTROLOptional. *Attendant control will be at no charge when ordered with Tilt and Recline, alternative drive controls, and a Q-Logic Display or SCIM module. Mounting bracket is included.
Attendant Control ....................................................................................................................................................... $500*NE+ & Static Back part: ELE125264. NE+ & Back Canes part: ELE165226. QL3 & Static Back part: ELE167862. QL3 & Back Canes part: ELE168031. HCPCS: E2331
17. TRU-BALANCE 3 POWER POSITIONING ELECTRONICSREQUIRED with power seating or legrest options.
Power Articulating Foot Platform ...................................$2,995Part: PTOINDV3754. HCPCS: E1012+K0040
Manually Adjustable Center Mount Foot Platform ............ Standard8"-12" extension part: RIG1802138. Other extensions: RIG1710345.
19.1. Center Mount Foot PlatformIf power articulating foot platform is selected, be sure power legrest control has been selected in earlier section. Select legrest length in following section.
2. Lower Extension and Angle Adjustable Footplates
1. Foot Platform Assembly
Power ArticulatingFoot Platform
Small Calf Pads (pair) 6”Wx6”H ......................................................................................................$150*Part: RIGASMB7120018
3. Center Mount Calf Support*Calf pads are standard with a power articulating foot platform.
This rigging configuration causes no interference issues at this seat-to-floor height.This rigging configuration may have less than 1.75” clearance when fully extended and may interfere with the ground or reduce obstacle climbing ability.
60°-90° Swing-Away Legrest Compatibility Matrix
Power Reclineor Static Seat
Low Med. High Low Med. High Low Med. High
Power Tilt Power Lift
Extruded, 11”-16.5”
11”-13” extension causes no interference at all seat-to-floor heights.
60°-90° Swing-Away Legrest .....................$81 ea. or N/C*Pair part: RIG120062. Left: FRMASMB17558. Right: FRMASMB17559*No charge with Power Positioning. Not available with 11"-13" extensions.
60°-90° Swing-Away Legrest, Short ............$81 ea. or N/C*Pair part: RIG136481. Left: RIG132607. Right: RIG132609.*No charge with Power Positioning. For use only with 11"-13" lower extensions.
19.2. Swing-Away LegrestsSelect a legrest upper, a legrest extension, and type of footplate. Pair (P), left (L), and right (R) configurations are selected by checking the appropriate boxes.1a. 60°-90° Swing-Away Legrest UpperAdjustable in 5° increments.
1b. 70° Swing-Away Legrest UpperOnly available with occupied transit WC-19 selections. Sold only in pairs. Select lower extension and footplates as pairs.
70° Swing-Away Legrest (pair) ..........................................$162Pair part: FRMASMB7841Not available with 11"-13" extensions.
70° Tapered, Swing-Away Legrest (pair) .............................$162Pair part: FRMASMB8052Not available with 11"-13" extensions.
70° Tapered, Swing-Away Legrest, Short (pair) .....................$162Pair part: FRMASMB7843For use only with 11"-13" lower extensions.
Reversed Dartex Calf Pad Cover (pair) ............................... $150Small part: RIG133717. Large part: RIG133719
5"x8" Tapered Gel Footplate Covers .................................. $205Part: ST-FPG5008T-Q. HCPCS: K0108
5"x11" Tapered Gel Footplate Covers ................................. $225Part: ST-FPG5011T-Q. HCPCS: K0108
6.5"x8" Tapered Gel Footplate Covers for Width Extension ..... $225Part: ST-FPG6508T-Q. HCPCS: K0108
7"x11" Tapered Gel Footplate Cover for Width Extension ....... $250Part: ST-FPG7011T-Q. HCPCS: K0108
6. Stealth Gel Footplate Covers
Width Extension for 8”D Footplates ...................................$50Part: RIG152517
Width Extension for 11”D Footplates ..................................$50Part: RIG152518
2” Bell-Shaped Length Extension .......................................$50Part: RIG152519Not compatible with width extensions. Can be used with 6” outside edge with 11” footplates.
4” Outside Edge (pair) .....................................................$50Part: RIG152510Only available with 6”D footplates and 8”D footplate extension.
6” Outside Edge (pair) .....................................................$50Part: RIG152516Available with 8”D and 11”D footplates and 11”D footplate extension.
4. Center Mount Modular Footplate Extension ComponentsOptional. Assembly required. May require seating configuration adjustments to avoid front caster interference.
19. LEGRESTSOptional. All efforts will be made to accommodate legrest length selection, but minor changes may need to be made to meet shipping guidelines. Some adjustments may be needed upon receipt of the unit. Reference the section’s compatibility matrix for legrest interference.
Page 12 of 18INFINFB4179/RevB/22JAN2020
1. Articulating Legrest Upper Assembly
19.3. 70° Power Articulating, Swing Away Legrests4” of articulating range. Be sure power legrest control has been selected in previous section. Select an upper extension type and footplate. Pair (P), left (L), and right (R) configurations are selected by checking the appropriate boxes. Select legrest length in following section.
70° Articulating, Swing-Away .......................$1,197.50 ea.Legrest with 14.5"-18" ExtensionPair Part: FRMASMB9073. Left Part: FRMASMB9074. Right Part: FRMASMB9075. HCPCS: E1010+K0040+E0951
70° Articulating, Swing-Away .......................$1,197.50 ea.Legrest with 11"-13" ExtensionPair Part: FRMASMB11444. Left Part: FRMASMB11366. Right Part: FRMASMB11367. HCPCS: E1010+K0040+E0951
This rigging configuration causes no interference issues at this seat-to-floor height.This rigging configuration may have less than 1.75” clearance when fully extended and may interfere with the ground or reduce obstacle climbing ability.
70° Power Articulating,Swing-Away Legrest Compatibility Matrix
Power Reclineor Static Seat
Low Med. High Low Med. High Low Med. High
Power Tilt Power Lift
Angle Adjustable, 11”-13”
Angle Adjustable, 14.5”-18”
4. Swing-Away Legrest Accessories
5. Amputee Supports with Swing-Away UpperEnter a quantity for the amputee supports and covers. A 60°-90° legrest upper must be selected with the amputee support. The support will be configured with the legrest upper side that does not have a lower extension and footplate selected with it.
Heel Loops (pair) ............................................................$50Part: FRMASMB7873. HCPCS: E0951Standard on angle adjustable and multi-axis footplates.
Wheel Bumper ...................................................... $12.50 ea.Part: See XRef
Gel Neoprene Footrest Sleeve (pair) ...................................$80Part: INDPART2243. HCPCS: K0108
Therafin 32387 Amputee Support Gel Cover ..............$155 ea.Part: INDPART2823. HCPCS: K0108
3c. Swing Away Legrest, Multi-Axis Footplate(s) with Heel Loops¹The 6”x11” footplates may cause interference with seat widths less than 18”. ²The 8”x11” footplates may cause interference with seat widths less than 20”.
8.5”Wx6”D Extruded Footplate ......................... StandardPart pair: FRMASMB7848. Left: FRMASMB7863 Right: FRMASMB7864May cause interference on seat widths less than 18.”
11”-13” LengthPart: See XRefN/A with Multi-axis.
11”-16.5” LengthPart: See XRefN/A with Angle Adjustable.
13”-16.5” LengthPart: See XRefN/A with Multi-Axis.
15.5”-19.5” LengthPart: See XRef
2. Lower Extension
3b. Swing-Away Legrest, Angle Adjustable Footplate(s) with Heel Loops¹The 6”x11” footplates may cause interference with seat widths less than 18”. ²The 8”x11” footplates may cause interference with seat widths less than 20”.
4”Wx6”DPair part: FRMASMB7448. Left part: RIG133543. Right part: RIG133566.
5”Wx6”DPair part: FRMASMB7449. Left part: RIG133544. Right part: RIG133567.
5”Wx8”DPair part: FRMASMB7450. Left part: RIG133545. Right part: RIG133568.
6”Wx8”D1Pair part: FRMASMB7451. Left part: RIG133547. Right part: RIG133569.
6”Wx11”D1Pair part: FRMASMB7452. Left part: RIG133548. Right part: RIG133570.
8”Wx11”D2Pair part: FRMASMB7453. Left part: RIG133549. Right part: RIG133571.
2. Angle Adjustable Footplate with Heel Loop and Wheel Bumper¹The 6”x11” footplates may cause interference with seat widths less than 18”. ²The 8”x11” footplates may cause interference with seat widths less than 20”.
19. LEGRESTS continued
Page 13 of 18INFINFB4179/RevB/22JAN2020
3. Power Articulating, Swing-Away Legrest AccessoriesCalf Pad (pair) 6”Wx6”H .......................................... No ChargePart: MEC153735
Falcon Gel Padded Knee Adductor Buttons (KBE)(pair) ...........$125Part: INDPART2242. HCPCS: E0953^^Please verify the appropriate billing code with all third-party payors.
1. Elevating Legrests Upper
2. Lower Extension11”-14” LengthPair: FRMASMB4755Left: RIG138026Right: RIG138030For reinforced only
12”-14.5” LengthPart: See XRefFor angle adjustable only
14”-17” LengthPair: FRMASMB4756Left: RIG138033Right: RIG138035For reinforced only
14.5”-18” LengthPart: See XRefFor angle adjustable only
This rigging configuration causes no interference issues at this seat-to-floor height.This rigging configuration may have less than 1.75” clearance when fully extended and may interfere with the ground or reduce obstacle climbing ability.
19.4. Elevating LegrestsSelect a legrest upper, a legrest extension, and type of footplate. Pair (P), left (L), and right (R) configurations are selected by checking the appropriate boxes. Select legrest length in following section.
8.5”Wx6”D Reinforced Footplate ....................... StandardPair part: FRMASMB4747. Left: RIG138060. Right: RIG138062May cause interference on seat widths less than 18.”
3b. Angle Adjustable Footplate(s)¹The 6”x11” footplates may cause interference with seat widths less than 18”. ²The 8”x11” footplates may cause interference with seat widths less than 20”. 4"x6" and 5"x6" footplates are only available in pairs.
Wheel Bumper ...................................................... $12.50 ea.Part: See XRefAvailable on angle adjustable footplates.
Falcon Gel Padded Knee Adductor Buttons (KBE) (pair) ..........$125Part: INDPART2242. HCPCS: E0953^^Please verify the appropriate billing code to be used for this item with all third-party payors.
20. SET LEGREST EXTENSION LENGTHREQUIRED with matching left and right legrest configuration. All efforts will be made to accommodate legrest length selection, but minor changes may need to be made to meet shipping guidelines. Some adjustments may be needed upon receipt of the unit. Reference the section’s compatibility matrix for legrest interference. Non-matching or individual legrest configurations lengths are not set by the manufacturer.
Push Handles (pair) ....................................... $175Part: ACC147772Not available with oxygen holder, back cane option, or vent tray. Required with attendant manual recline.
Accessory Bar ..............................................$100Part: MEC125098Horizontal rail attached to rear of seat. Standard with the Trilogy vent tray and oxygen holder. Not available with back cane option.
Non-matching Joystick Shroud.......................... $50Select color below
Match Joystick Shroud to Base Color .................. $50Part: See color below
Q-Logic 3 Enhanced Display Kit .....................................................................................................$1,720Part: CTL167726Select a color option below. Includes enhanced display, flexible gooseneck and mounting bracket. Features: 3.5” LCD display; up to 5 profiles to control drive, seat, and auxiliary functions; Bluetooth connectivity for mobile devices and mouse emulation; integrated single switch scanner; IR controls.
Red CorvettePart: DGN137729-PRD1
Cherry BombPart: DGN137729-PRD4
Back in BlackPart: DGN137729-PBK1
Night TrainPart: DGN137729-PBK3
Grey StreetPart: DGN137729-PSL3
White SatinPart: DGN137729-PWH2
Deep PurplePart: DGN137729-PPR5
Raspberry BeretPart: DGN137729-PPK4
Pretty in PinkPart: DGN137729-PPK3
Evolution OrangePart: DGN137729-POR7
Midnight BluePart: DGN137729-PBU10
Electric BluePart: DGN137729-PBU9
Blue JeanPart: DGN137729-PBU11
Lemon CrushPart: DGN137729-PYL4
Green MachinePart: DGN137729-PGN11
Military GreenPart: DGN137729-PGN8
Sugar PlumPart: DGN137729-PPR7
To Be DeterminedFollow-up required.
23. ALTERNATIVE CONTROLS AND ELECTRONICSOptional. Select a type of specialty controls below. More options are available on the Alternative Controls and Electronics order form.
Alternative controls and electronics section continued on following page.
23.4. Head ArrayAdult, i-Drive Tri-Array Series, 3-Switch ......... $4,414Head Array (IDHBT200-1)Part: ST-IDHBT200-1-Q. HCPCS: E2330Features bluetooth, head support, 3 non-proportional proximity sensors for drive control, an egg switch for re-set mode change, and i-Drive smart box.
Adult, i-Drive Pro Series Head Array .............. $4,461(IDHBT300-1)Part: ST-IDHBT300-1-Q. HCPCS: E2330Features bluetooth, head support with occipital pad and 2 swing-away spot pads for left and right side, 3 non-pro-portional proximity sensors, an egg switch for reset mode change, and i-Drive smart box.
Adult Pro-Series
23.3. Q-Logic 3 SAJQ-Logic 3 EX SAJ .........................................................................................................................$700Part: CTL143980Must be used in conjunction with Enhanced Display or Q-Logic 3 Joystick.
EX SAJ
Stealth Sip and Puff for Comfort Series, .........$294.25Left Mount (SP625-CL)Part: ST-SP625-CL-Q. HCPCS: E2326 Includes straw and mounting hardware. Use with Stealth Comfort Plus headrests.
Stealth Sip and Puff for Comfort Series, .........$294.25Right Mount (SP622-CR)Part: ST-SP625-CR-Q. HCPCS: E2326Includes straw and mounting hardware. Use with Stealth Comfort Plus headrests.
Stealth Sip and Puff for Stealth i-Drive, .........$294.25Head Array (SP625-U)Part: ST-SP625-U-Q. HCPCS: E2326 Includes straw and mounting hardware. Use with Stealth i-Drive Head Arrays.
Stealth Sip & Puff
Sip and Puff Module for Q-Logic 3 ..................................................................................................$1,895Part: CTL168056. HCPCS: E2325 Includes module and mounting hardware.
Sip & Puff Module
23.5. Sip and Puff Drive1. Sip and Puff Module
2. Sip and Puff Straw and Mount
SCIM Module for Q-Logic 3 ............................................................................................................. $525Part: CTL168055Allows use of joystick display for specialty devices. Available with Q-Logic 3 EX Joystick selection above. Up to 5 profiles to control drive, seat, and auxiliary functions, excluding sip-n-puff and single switch functions. A switch is required to operate the input device attached to the SCIM module. SCIM Module
23.2. SCIM ModuleOptional.
Egg Switch
Red Egg Switch (ESRED) .......................... $80.85Part: SWTMCRO1077
Blue Egg Switch (ESBLU) ......................... $80.85Part: SWTMCRO1079
Black Egg Switch (ESBLK) ........................ $80.85Part: SWTMCRO1081
Green Egg Switch (ESGRN) ...................... $80.85Part: SWTMCRO1078
23.7. Switch Adapter2 to 1 Switch Adapter .................................................................................................................................................. $13.39Part: DWR1361H037 Connects 2 single switches to a stereo jack to act as a dual switch.
USB Mobile Device Charger ............................................................................................................ $175Part: ELE168069Can charge 1 device. A multiplier harness is required and must be added when a Static Seat or Power Tilt Only seating system is chosen. The selection of more than 3 modules requires an additional multiplier. USB Mobile
Flip Down with LEFT Full Surface Contact ................. $236.25 ea.Feature (TWBADD-L & LPHW407)Part: POS140428. HCPCS: E1028
Flip Down with RIGHT Full Surface Contact ................ $236.25 ea.Feature (TWBADD-R & LPHW407)Part: POS140429. HCPCS: E1028
1. Pelvic/Thigh Guide Bracket
2. Pelvic/Thigh Guide Adapter
24.3. Stealth Pelvic/Thigh GuidesPelvic/thigh guides may interfere with the joystick receiver block and down posts. Please provide quantity next to check box.
2” Height Adapter Plate (LHW-122) .................................$26.25Part: INDPART2821. HCPCS: K0108Height adapter is needed with TRU-Comfort seat cushions. Not avail-able with the flip down bracket.
2 1/4” Adapter Plate (LHW-129) .....................................$53.50Part: POS140430. HCPCS: K0108Only available with the flip down full surface bracket.
3. Pelvic/Thigh Guide Pad^Please verify the appropriate billing code to be used for this item with all third-party payors.
4. Pelvic/Thigh Guide Installation
Short Pad, 4”x4” (TWBADD-4X4) ..............................$75 ea.Part: INDPART2801. HCPCS: E0953^/E0956
Medium Pad, 4”x8” (TWBADD-4X8) ...........................$75 ea.Part: INDPART2802. HCPCS: E0953^/E0956
Long Pad, 4”x12” (TWBADD-4X12) ............................$75 ea.Part: INDPART2803. HCPCS: E0953^/E0956
24.1. Stealth Thoracic LateralsSwing-away laterals may interfere with TRU-Balance 3 armrests and 2-post, flip up armrests. These laterals are not available with the back cane option.
24. POSITIONING COMPONENTSOptional. More options are available on the Positioning Components Order Form.
Positioning components section continued on following page.
Swing-Away Joystick Mount, 18" Rod (C) .... $250 ea.Part: ST-SUS18-Q Allows mounting of facial pads and attaches to the headrest
24.6. Stealth Swing-Away Headrest MountsThese swing-away headrest mounts are only available with the Stealth Comfort Series headrests. The 1" ball kit must be selected to mount the facial lateral to the headrest bracket. Also select a facial pad(s) with the facial lateral(s).
Facial Lateral for Comfort Series .............$294.25 ea.Right Side (CPS9-R-HW)Part: INDPART2647. HCPCS: E1028
Facial Lateral for Comfort Series .............$294.25 ea.Left Side (CPS9-L-HW)Part: INDPART2648. HCPCS: E1028
Facial Laterals for Comfort Series ........... $347.75 ea.Left and Right Side (CPS9-B-HW)Part: INDPART2649. HCPCS: E1028
Left and Right FacialLateral with Pads
Headrest Accessories
24.5. Stealth i-Fit Chest StrapsChest Strap, Medium w/ Belt Anchor, (IFCS4113) ..$90 ea.Part: ST-IFCS4113-Q. HCPCS: E0960
Chest Strap, Large w/ Belt Anchor, (IFCS4114) ....$90 ea.Part: ST-IFCS4114-Q. HCPCS: E0960
25. TRU-BALANCE 3 MULTIPLIER HARNESSREQUIRED. Multiple controllers or power accessories may require an additional multiplier harness or special order. Reference the chart below to determine the appropriate selection. The rows refer to the total amount of arm mounted de-vices and the columns refer to the total amount of back mounted devices. The online order configurator will automatically make this selection under specialty controls.
26. REFERENCE ORDER FORMSOptional. Select below to note that additional order forms will accompany this order form. This will also be a link in interactive forms.
Alternative Controls & Electronics Order Form Positioning Components Order Form
No Additional Multiplier (NA) .................................... No ChargePart: Configuration selection
No Charge SET1902613 SEAT BACK,ASSY,16"W,16"W-20"W,19"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1902625 SEAT BACK,ASSY,16"W,16"W-20"W,21"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1902637 SEAT BACK,ASSY,16"W,16"W-20"W,23"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1907173 SEAT BACK,ASSY,16"W,16"W-20"W,25"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1902551 SEAT BACK,ASSY,17"W,16"W-20"W,13"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1902571 SEAT BACK,ASSY,17"W,16"W-20"W,15"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1902601 SEAT BACK,ASSY,17"W,16"W-20"W,17"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1902614 SEAT BACK,ASSY,17"W,16"W-20"W,19"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1902626 SEAT BACK,ASSY,17"W,16"W-20"W,21"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1902638 SEAT BACK,ASSY,17"W,16"W-20"W,23"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1907174 SEAT BACK,ASSY,17"W,16"W-20"W,25"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1902553 SEAT BACK,ASSY,18"W,18"W-22"W,13"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1902574 SEAT BACK,ASSY,18"W,18"W-22"W,15"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1902603 SEAT BACK,ASSY,18"W,18"W-22"W,17"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1902616 SEAT BACK,ASSY,18"W,18"W-22"W,19"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1902628 SEAT BACK,ASSY,18"W,18"W-22"W,21"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1902640 SEAT BACK,ASSY,18"W,18"W-22"W,23"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1907175 SEAT BACK,ASSY,18"W,18"W-22"W,25"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1902554 SEAT BACK,ASSY,19"W,18"W-22"W,13"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1902575 SEAT BACK,ASSY,19"W,18"W-22"W,15"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1902604 SEAT BACK,ASSY,19"W,18"W-22"W,17"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1902617 SEAT BACK,ASSY,19"W,18"W-22"W,19"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1902629 SEAT BACK,ASSY,19"W,18"W-22"W,21"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1902641 SEAT BACK,ASSY,19"W,18"W-22"W,23"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1907176 SEAT BACK,ASSY,19"W,18"W-22"W,25"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1902555 SEAT BACK,ASSY,20"W,18"W-22"W,13"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1902576 SEAT BACK,ASSY,20"W,18"W-22"W,15"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1902605 SEAT BACK,ASSY,20"W,18"W-22"W,17"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1902618 SEAT BACK,ASSY,20"W,18"W-22"W,19"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1902630 SEAT BACK,ASSY,20"W,18"W-22"W,21"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1902643 SEAT BACK,ASSY,20"W,18"W-22"W,23"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1902866 SEAT BACK,ASSY,20"W,18"W-22"W,25"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1902556 SEAT BACK,ASSY,21"W,18"W-22"W,13"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1902577 SEAT BACK,ASSY,21"W,18"W-22"W,15"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1902606 SEAT BACK,ASSY,21"W,18"W-22"W,17"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1902619 SEAT BACK,ASSY,21"W,18"W-22"W,19"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1902631 SEAT BACK,ASSY,21"W,18"W-22"W,21"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1902644 SEAT BACK,ASSY,21"W,18"W-22"W,23"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1902858 SEAT BACK,ASSY,21"W,18"W-22"W,25"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1902713 SEAT BACK,ASSY,22"W,20"W-24"W,13"H,SPORT BACK 4,TRU-BALANCE 3 No Charge SET1902714 SEAT BACK,ASSY,22"W,20"W-24"W,15"H,SPORT BACK 4,TRU-BALANCE 3 No Charge SET1902715 SEAT BACK,ASSY,22"W,20"W-24"W,17"H,SPORT BACK 4,TRU-BALANCE 3 No Charge SET1902727 SEAT BACK,ASSY,22"W,20"W-24"W,19"H,SPORT BACK 4,TRU-BALANCE 3 No Charge SET1902729 SEAT BACK,ASSY,22"W,20"W-24"W,21"H,SPORT BACK 4,TRU-BALANCE 3 No Charge SET1902645 SEAT BACK,ASSY,22"W,18"W-22"W,23"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1902859 SEAT BACK,ASSY,22"W,18"W-22"W,25"H,SPORT BACK 4,TRU BALANCE 3 No Charge SET1902738 SEAT BACK,ASSY,24"W,20"W-24"W,13"H,SPORT BACK 4,TRU-BALANCE 3 No Charge SET1902741 SEAT BACK,ASSY,24"W,24"W-28"W,13"H,SPORT BACK 4,TRU-BALANCE 3 No Charge SET1902745 SEAT BACK,ASSY,24"W,20"W-24"W,17"H,SPORT BACK 4,TRU-BALANCE 3 No Charge SET1902746 SEAT BACK,ASSY,24"W,24"W-28"W,17"H,SPORT BACK 4,TRU-BALANCE 3 No Charge SET1902747 SEAT BACK,ASSY,24"W,20"W-24"W,19"H,SPORT BACK 4,TRU-BALANCE 3 No Charge SET1902748 SEAT BACK,ASSY,24"W,24"W-28"W,19"H,SPORT BACK 4,TRU-BALANCE 3 No Charge SET1902749 SEAT BACK,ASSY,24"W,20"W-24"W,21"H,SPORT BACK 4,TRU-BALANCE 3 No Charge SET1902750 SEAT BACK,ASSY,24"W,24"W-28"W,21"H,SPORT BACK 4,TRU-BALANCE 3
ADI Q-Back, Active Contour $525 ALBR16SAQ Q-BACK,AL SERIES,ACTIVE CONTOUR,16"W,16"H,(ADI)$525 ALBR16TAQ Q-BACK,AL SERIES,ACTIVE CONTOUR,16"W,18"H,(ADI)
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Option Name MSRP Part Number Manufacturer Extended Description
ADI Q-Back, Extra Deep Contour $650 ALBR16S6Q Q-BACK,AL SERIES,EXTRA DEEP CONTOUR,16"W,16"H,(ADI)$650 ALBR16T6Q Q-BACK,AL SERIES,EXTRA DEEP CONTOUR,16"W,18"H,(ADI)$650 ALBR18S6Q Q-BACK,AL SERIES,EXTRA DEEP CONTOUR,18"W,16"H,(ADI)$650 ALBR18T6Q Q-BACK,AL SERIES,EXTRA DEEP CONTOUR,18"W,18"H,(ADI)$650 ALBR20S6Q Q-BACK,AL SERIES,EXTRA DEEP CONTOUR,20"W,16"H,(ADI)$650 ALBR20T6Q Q-BACK,AL SERIES,EXTRA DEEP CONTOUR,20"W,18"H,(ADI)
TRU-Comfort Back, 20" Width or less $675 SET123622 SEAT BACK,ASSY,12"W,10"W-14"W,11"H,TRU-COMFORT 2,4 WAY STRETCH$675 SET123623 SEAT BACK,ASSY,14"W,10"W-14"W,13"H,TRU-COMFORT 2,4 WAY STRETCH$675 SET123631 SEAT BACK,ASSY,16"W,16"W-20"W,13"H,TRU-COMFORT 2,4 WAY STRETCH$675 SET123633 SEAT BACK,ASSY,16"W,16"W-20"W,15"H,TRU-COMFORT 2,4 WAY STRETCH$675 SET123635 SEAT BACK,ASSY,16"W,16"W-20"W,17"H,TRU-COMFORT 2,4 WAY STRETCH$675 SET123637 SEAT BACK,ASSY,16"W,16"W-20"W,19"H,TRU-COMFORT 2,4 WAY STRETCH$675 SET123639 SEAT BACK,ASSY,17"W,16"W-20"W,13"H,TRU-COMFORT 2,4 WAY STRETCH$675 SET123641 SEAT BACK,ASSY,17"W,16"W-20"W,15"H,TRU-COMFORT 2,4 WAY STRETCH$675 SET123651 SEAT BACK,ASSY,17"W,16"W-20"W,17"H,TRU-COMFORT 2,4 WAY STRETCH$675 SET123653 SEAT BACK,ASSY,17"W,16"W-20"W,19"H,TRU-COMFORT 2,4 WAY STRETCH$675 SET123655 SEAT BACK,ASSY,18"W,16"W-20"W,13"H,TRU-COMFORT 2,4 WAY STRETCH$675 SET124576 SEAT BACK,ASSY,18"W,16"W-20"W,15"H,TRU-COMFORT 2,4 WAY STRETCH$675 SET124578 SEAT BACK,ASSY,18"W,16"W-20"W,17"H,TRU-COMFORT 2,4 WAY STRETCH$675 SET124597 SEAT BACK,ASSY,18"W,16"W-20"W,19"H,TRU-COMFORT 2,4 WAY STRETCH$675 SET124599 SEAT BACK,ASSY,18"W,16"W-20"W,21"H,TRU-COMFORT 2,4 WAY STRETCH$675 SET124601 SEAT BACK,ASSY,19"W,16"W-20"W,13"H,TRU-COMFORT 2,4 WAY STRETCH$675 SET124602 SEAT BACK,ASSY,19"W,16"W-20"W,15"H,TRU-COMFORT 2,4 WAY STRETCH$675 SET124603 SEAT BACK,ASSY,19"W,16"W-20"W,17"H,TRU-COMFORT 2,4 WAY STRETCH$675 SET124605 SEAT BACK,ASSY,19"W,16"W-20"W,19"H,TRU-COMFORT 2,4 WAY STRETCH$675 SET124606 SEAT BACK,ASSY,20"W,16"W-20"W,13"H,TRU-COMFORT 2,4 WAY STRETCH$675 SET124607 SEAT BACK,ASSY,20"W,20"W-24"W,13"H,TRU-COMFORT 2,4 WAY STRETCH$675 SET124609 SEAT BACK,ASSY,20"W,16"W-20"W,15"H,TRU-COMFORT 2,4 WAY STRETCH$675 SET124610 SEAT BACK,ASSY,20"W,20"W-24"W,15"H,TRU-COMFORT 2,4 WAY STRETCH$675 SET124611 SEAT BACK,ASSY,20"W,16"W-20"W,17"H,TRU-COMFORT 2,4 WAY STRETCH$675 SET124612 SEAT BACK,ASSY,20"W,20"W-24"W,17"H,TRU-COMFORT 2,4 WAY STRETCH$675 SET124613 SEAT BACK,ASSY,20"W,16"W-20"W,19"H,TRU-COMFORT 2,4 WAY STRETCH$675 SET124618 SEAT BACK,ASSY,20"W,20"W-24"W,19"H,TRU-COMFORT 2,4 WAY STRETCH$675 SET124619 SEAT BACK,ASSY,20"W,16"W-20"W,21"H,TRU-COMFORT 2,4 WAY STRETCH$675 SET124623 SEAT BACK,ASSY,20"W,20"W-24"W,21"H,TRU-COMFORT 2,4 WAY STRETCH$675 TC4V10W22W TRU COMFORT 4 VISCO, UP TO 22" WIDE
TRU-Comfort Back, 22" Width or greater $775 SET124624 SEAT BACK,ASSY,22"W,20"W-24"W,13"H,TRU-COMFORT 2,4 WAY STRETCH$775 SET124625 SEAT BACK,ASSY,22"W,20"W-24"W,15"H,TRU-COMFORT 2,4 WAY STRETCH$775 SET124626 SEAT BACK,ASSY,22"W,20"W-24"W,17"H,TRU-COMFORT 2,4 WAY STRETCH$775 SET124627 SEAT BACK,ASSY,22"W,20"W-24"W,19"H,TRU-COMFORT 2,4 WAY STRETCH$775 SET124628 SEAT BACK,ASSY,24"W,20"W-24"W,13"H,TRU-COMFORT 2,4 WAY STRETCH$775 SET130059 SEAT BACK,ASSY,24"W,24"W-28"W,13"H,TRU-COMFORT 2,4 WAY STRETCH$775 SET124629 SEAT BACK,ASSY,24"W,20"W-24"W,15"H,TRU-COMFORT 2,4 WAY STRETCH$775 SET130060 SEAT BACK,ASSY,24"W,24"W-28"W,15"H,TRU-COMFORT 2,4 WAY STRETCH$775 SET124630 SEAT BACK,ASSY,24"W,20"W-24"W,17"H,TRU-COMFORT 2,4 WAY STRETCH$775 SET130061 SEAT BACK,ASSY,24"W,24"W-28"W,17"H,TRU-COMFORT 2,4 WAY STRETCH
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Option Name MSRP Part Number Manufacturer Extended Description
TRU-Balance 3 Armrest Downpost $87.50 MEC140975 DOWN POST,ASSY,8"H-11"H,STRAIGHT,LEFT,TRU-BALANCE 3$87.50 MEC140977 DOWN POST,ASSY,12"H,STRAIGHT,LEFT,TRU-BALANCE 3$87.50 MEC140979 DOWN POST,ASSY,13"H-14"H,STRAIGHT,LEFT,TRU-BALANCE 3$87.50 MEC140981 DOWN POST,ASSY,15"H,STRAIGHT,LEFT,TRU-BALANCE 3$87.50 MEC140983 DOWN POST,ASSY,16"H,STRAIGHT,LEFT,TRU-BALANCE 3$87.50 MEC140976 DOWN POST,ASSY,8"H-11"H,STRAIGHT,RIGHT,TRU-BALANCE 3$87.50 MEC140978 DOWN POST,ASSY,12"H,STRAIGHT,RIGHT,TRU-BALANCE 3$87.50 MEC140980 DOWN POST,ASSY,13"H-14"H,STRAIGHT,RIGHT,TRU-BALANCE 3$87.50 MEC140982 DOWN POST,ASSY,15"H,STRAIGHT,RIGHT,TRU-BALANCE 3$87.50 MEC140984 DOWN POST,ASSY,16"H,STRAIGHT,RIGHT,TRU-BALANCE 3$87.50 MEC140410 DOWN POST,ASSY,8"H-11"H,ENDOMORPH,LEFT,TRU-BALANCE 3$87.50 MEC140416 DOWN POST,ASSY,12"H,ENDOMORPH,LEFT,TRU-BALANCE 3$87.50 MEC140417 DOWN POST,ASSY,13"H-14"H,ENDOMORPH,LEFT,TRU-BALANCE 3$87.50 MEC140418 DOWN POST,ASSY,15"H,ENDOMORPH,LEFT,TRU-BALANCE 3$87.50 MEC140419 DOWN POST,ASSY,16"H,ENDOMORPH,LEFT,TRU-BALANCE 3$87.50 MEC140990 DOWN POST,ASSY,8"H-11"H,ENDOMORPH,RIGHT,TRU-BALANCE 3$87.50 MEC140991 DOWN POST,ASSY,12"H,ENDOMORPH,RIGHT,TRU-BALANCE 3$87.50 MEC140992 DOWN POST,ASSY,13"H-14"H,ENDOMORPH,RIGHT,TRU-BALANCE 3$87.50 MEC140993 DOWN POST,ASSY,15"H,ENDOMORPH,RIGHT,TRU-BALANCE 3$87.50 MEC140994 DOWN POST,ASSY,16"H,ENDOMORPH,RIGHT,TRU-BALANCE 3
ARMRESTS : TRU-Balance 3 Flip-Back Armrests
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Option Name MSRP Part Number Manufacturer Extended Description
$87.50 MEC166424 DOWN POST,ASSY,8"H-11"H,MESOMORPH,LEFT,TRU-BALANCE 3$87.50 MEC166429 DOWN POST,ASSY,12"H,MESOMORPH,LEFT,TRU-BALANCE 3$87.50 MEC166430 DOWN POST,ASSY,13"H-14"H,MESOMORPH,LEFT,TRU-BALANCE 3$87.50 MEC166431 DOWN POST,ASSY,15"H,MESOMORPH,LEFT,TRU-BALANCE 3$87.50 MEC166432 DOWN POST,ASSY,16"H,MESOMORPH,LEFT,TRU-BALANCE 3$87.50 MEC166433 DOWN POST,ASSY,8"H-11"H,MESOMORPH,RIGHT,TRU-BALANCE 3$87.50 MEC166435 DOWN POST,ASSY,12"H,MESOMORPH,RIGHT,TRU-BALANCE 3$87.50 MEC166436 DOWN POST,ASSY,13"H-14"H,MESOMORPH,RIGHT,TRU-BALANCE 3$87.50 MEC166437 DOWN POST,ASSY,15"H,MESOMORPH,RIGHT,TRU-BALANCE 3$87.50 MEC166438 DOWN POST,ASSY,16"H,MESOMORPH,RIGHT,TRU-BALANCE 3
2-Post, Flip Back, Height Adjustable, removable Armrests (9"-13" No Charge
FRMASMB7062 ARMREST,ASSY,ADULT TWO POST FLIP-UP HEIGHT ADJUSTABLE,FULL LENGTH,VERSION No Charge
FRMASMB7063 ARMREST,ASSY,ADULT TWO POST FLIP-UP HEIGHT ADJUSTABLE,FULL LENGTH,VERSION No Charge
FRMASMB7060 ARMREST,ASSY,ADULT TWO POST FLIP-UP HEIGHT ADJUSTABLE,DESK LENGTH,VERSION No Charge
FRMASMB7061 ARMREST,ASSY,ADULT TWO POST FLIP-UP HEIGHT ADJUSTABLE,DESK LENGTH,VERSION