Page 1 of 18 INFINFB3952/RevE/08APR2019 Q6 Edge ® 3 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 8 amp off board charger. XLR USB charger is included. Dimensions of base without legrests: 24”Wx35.5”L Quantum Q6 Edge 3 3S-SS ............................................ $7,895 Part: Q6 EDGE 3 3S-SS. HCPCS: K0848 Solid seat pan standard with no power option. Quantum Q6 Edge 3 3SP-SS ........................................... $7,895 Part: Q6 EDGE 3 3SP-SS. HCPCS: K0856 Single power option. Quantum Q6 Edge 3 3MP-SS .......................................... $7,895 Part: Q6 EDGE 3 3MP-SS. HCPCS: K0861 Multiple actuator power option.
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Page 1 of 18INFINFB3952/RevE/08APR2019
Q6 Edge® 3 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 8 amp off board charger. XLR USB charger is included. Dimensions of base without legrests: 24”Wx35.5”L
Quantum Q6 Edge 3 3S-SS ............................................ $7,895Part: Q6 EDGE 3 3S-SS. HCPCS: K0848Solid seat pan standard with no power option.
8. BATTERIESREQUIRED. The powerchair requires 2 batteries and will be installed if ordered.
Base Mounted, LED, Full Light Package .............................................................................................$995Part without iLevel: ELE1705999. Part with iLevel: ELE168643Fender lights will be omited with Base Mounted, LED, Full Light Package.
Seat Mounted, LED, Full Light Package .............................................................................................$995Part: ELE131477 Seat Mounted LED
Lights (One Shown)
5. FULL LIGHT PACKAGESOptional. Requires NE+ 8 Key or Q-Logic 3 Joystick for Full Light Package. Select one available package below.
4. FENDER LIGHTSOptional. Fender lights operate by pressing included single switch button. Fender lighting is not available with Single Actuator Control through Toggle Box.
Fender Light Switch Mount TypeSide Rail/Track Mount Bracket .................................... StandardPart: MEC1800866Allows the egg switch to be mounted to seating side rails using a t-nut assembly. This may also be mounted to other armrest, seat or acces-sory bar rails. Not available with contoured seating.
Under Arm Mounting Bracket ............................................$25Part: MEC1802726Allows the egg switch to mount to a joystick tube-style bracket mounted to any armrest. Includes joystick mounting bracket.
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.
3.1. Match Colors
Page 3 of 18INFINFB3952/RevE/08APR2019
Back in Black ...........................StandardPart: DGN164245-PBK1 x2
Red Corvette .........................No ChargePart: DGN164245-PRD1 x2
9.2. Drive Wheel Accent ColorNot available with knobby tires.
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
10.1a. 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
10.1b. 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
10.2. 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.
10. 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.
Red CorvettePart: DGN124336-PRD1
Cherry BombPart: DGN124336-PRD4
Back in BlackPart: DGN124336-PBK1
Night Train*See Black, Soft Touch
Grey StreetPart: DGN124336-PSL3
White SatinPart: DGN124336-PWH2
Deep PurplePart: DGN124336-PPR5
Raspberry BeretPart: DGN124336-PPK4
Evolution OrangePart: DGN124336-POR7
Midnight BluePart: DGN124336-PBU10
Electric BluePart: DGN124336-PBU9
Blue JeanPart: DGN124336-PBU11
Lemon CrushPart: DGN124336-PYL4
Green MachinePart: DGN124336-PGN11
Military GreenPart: DGN124336-PGN8
Sugar PlumPart: DGN124336-PPR7
Military Digital CamoPart: DGN124336-WCM7
Faded GloryPart: DGN124336-WFL2
Carbon FiberPart: DGN124336-WCB1
To Be DeterminedFollow-up required.
Electronics section continued on following pages.
3”x14” Flat Free Black Tires ...................................... StandardPart: PTOINDV3525 (pair)
11. 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.
12.1b. 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.
12.1c. Specialty Joystick MountsSelect a bracket and side to mount it.
Specialty Mount Side
12.1a. Fixed, In-line Joystick Bracket
12. 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.
13.1. 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. Not avail-able with high speed motors or manual recline.
Attendant Manual Recline* ............................................. $500Part: PTOINDV3501. HCPCS: E1226*Available through Special Order when ordered with fender lights. Not available with NE+ joystick with Tilt through toggle. Available with Static Seat or Power Tilt. Not available with Power Lift.
13.2. 12" Power Lift or Manual ReclineOptional. Select one option below.
13. TRU-BALANCE® 3 SEATING - Quantum Intelligent Systems™REQUIRED. Maximum seat size is 22"W x 22"D.
TRU-Balance 3 Seating section continued on following pages.
Page 5 of 18INFINFB3952/RevE/08APR2019
Fluid Proof Urethane Liner ......................................... $50-$70Part: URL1709070-XXYYNot available with Simplicity or TRU-Comfort 2.
Fluid Proof Polyurethane Liner .................................... $55-$75Part: PUL1709030-XXYYNot available with Simplicity.
Match Seat Width and Depth
12” W14” W
15” W16" W
17" W18" W
19" W20" W
22" W 12" D14” D
15” D16" D
17" D18" D
19" D20" D
22" 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.
13.4. Seat Dimension - WidthREQUIRED with seat selection. Maximum seat width is 22". 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.
13.5. Seat Dimension - Width PackageREQUIRED with seat selection. Width and depth package part: See XRef: TB3SPACK
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
13.3. Occupied Transit KitOptional. The power base is standard with Unoccupied Transit Loops. 60” Sure-Lok Lap Belt is required with Occupied Transit Option.
13.9. 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-Comfort 2 SPP, E2607, 16"W to 20" W .........$400TRU-Comfort 2 SPP, E2608, 22"W .....................$500
Simplicity G, E2601, 16"W to 20" W ................... $110Simplicity G, E2602, 22"W .............................. $165
Solution SPP, E2607, 14"W to 20" W ..................$375Solution SPP, E2608, 22"W ..............................$430
Spectrum Gel SPP, E2607, 14"W to 20" W ...........$460Spectrum Gel SPP, E2608, 22"W .......................$530
Spectrum Foam SPP, E2607, 16"W to 20" W .........$460Spectrum Foam SPP, E2608, 22"W ....................$530
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
TRU-Balance 3 Back Assembly (Static Back)Part: Configuration selectionSelect 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.
Flip Forward Back......................................................... $150Part without Lift: MEC131957, Part with Lift: MEC148117Available with Static Seat and Power Tilt (1 actuator). Only available with 2-post, flip back or pediatric armrests. Not available with 12”-14” width or with attendant manual recline. Select a back cushion type in the subsequent section.
16”H CanePart: FRMASMB15834
17”H CanePart: FRMASMB15835
20”H CanePart: FRMASMB15838
21”H CanePart: FRMASMB15839
24”H CanePart: FRMASMB15842
25”H CanePart: FRMASMB15843
13.12. Back Cushion Configuration - TypeREQUIRED. 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 2 Back, 20” Width or less ............................. $675Part: See XRef. HCPCS: E2620Complete following width package and size.
TRU-Comfort 2 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”.
4. Seat Cushion Substitute CoverAn additional cover may be ordered or the standard cover may be substituted with a cover by checking the option in subsection 2. 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.
TRU-Balance 3 Seating section continued on following pages.
13. TRU-BALANCE 3 SEATING continued
13.13. 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 CorvettePart: DGN148034
Cherry BombPart: DGN1801259-PRD4
Back in BlackPart: DGN148032
Night TrainPart: DGN1706558
Grey StreetPart: DGN148074
White SatinPart: DGN148075
Deep PurplePart: DGN148046
Raspberry BeretPart: DGN1801259-PPK4
Evolution OrangePart: DGN1801259-POR7
Midnight BluePart: DGN148035
Electric BluePart: DGN148076
Blue JeanPart: DGN1801259-PBU11
Lemon CrushPart: DGN1801259-PYL4
Green MachinePart: DGN1801259-PGN11
Military GreenPart: DGN148037
Sugar PlumPart: DGN1801259-PPR7
Military Digital CamoPart: DGN1707171
Faded GloryPart: DGN1707173
Carbon FiberPart: DGN1707169
To Be DeterminedFollow-up required.
Page 7 of 18INFINFB3952/RevE/08APR2019
13.19. 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.
13.14. TRU-Balance 3 Power Base Interface Shroud (Power Tilt Side Shroud)REQUIRED with power tilt. The TRU-Balance 3 power base interface shrouds are located on the left and right interface plates of the TRU-Balance 3 system, which mount to the power base, and are available in most matching power base shroud colors. Reference colors shown on page 2.
Red CorvetteLift part: DGN1802631-PRD1 x2Non-lift part: DGN1709093-PRD1 x2
Lateral Positioning Wedge, pair ......................................................................................................................................... $30Part: SET123465Available with Sport and TRU-Comfort 2 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.
13.16. Back Cushion Configuration - 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, back cushions
16”W-20”W PackagePart: Configuration selection, back cushions
20”W-24”W PackagePart: Configuration selection, back cushions
13.17. 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)
13. 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
13.18. 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.
Tilt or Static Width Recline Width
Sport, Q-Back, and TRU-Comfort 2 Back Availability Chart
Ove
rall
Hei
ght
Sport or TRU-Comfort 2 BackSport BackSport, Q-Back, or TRU-Comfort 2 Back
Page 8 of 18INFINFB3952/RevE/08APR2019
14.2. 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
14.3. 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.
14. 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.
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.
Flip-Back, 8"-16"H Armrests .................................................................................................................................. StandardLeft part: ARM1806662. Right part: ARM1806663
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.
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.
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
14.1b. 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.
14.1a. 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.
14.1c. 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.
14.1d. 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 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
15.1b. 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
15. 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.
15.1a. 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.
Stealth 8” Comfort Plus (CP450) ................... $151.94Part: POS148484. HCPCS: E0955
Stealth 10” Comfort Plus (CP250)(A) ............. $151.94Part: SETHEAD1057. HCPCS: E0955
Stealth 14” Comfort Plus (CP150) ................. $151.94Part: INDPART2327. HCPCS: E0955
Pediatric Comfort Plus (6”Wx4.5”H) ............. $151.94(CPN350)Part: SETHEAD1069. HCPCS: E0955
Stealth Small Contoured (9.75”Wx3”H) .............$64.20(STL-OTSM250)Part: SETHEAD1052. HCPCS: E0955
Stealth Large Contoured (11”Wx6”H) (B) ........... $80.25(STL-OTLG150)Part: SETHEAD1053. HCPCS: E0955
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
18. LAP BELTSREQUIRED. Select a lap belt below.18.1a. Standard Lap Belts
18.1b. 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
19. 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
16. TRU-BALANCE 3 ARMREST BRACKETS
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)
16.1. Joystick BracketREQUIRED.
16.2. 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.
Single Actuator Control, Through Toggle (Power Tilt Only) ...............................................................................................No ChargePart: See XRefOnly available with Power Tilt only. Select toggle side. May require extended lead time when selected with Fender Lights.
Left Side Toggle Right Side TogglePart: PTOINDV1838 Part: PTOINDV1839
20.1a. Tilt Only through Toggle
20.1b. 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
20. TRU-BALANCE 3 POWER POSITIONING ELECTRONICSREQUIRED with power seating or legrest options.
Page 10 of 18INFINFB3952/RevE/08APR2019
20.1e. 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
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
20.1c. 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.
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
20.1d. Q-Logic 3 Controls with iAccess Switch ControliAccess control is not available with combined or independent power legrests.
iAccess Mount Location
20. TRU-BALANCE 3 POWER POSITIONING ELECTRONICS continued
Attendant Control ....................................................................................................................................................... $500*Part: ELE167862. HCPCS: E2331
21. 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.
8"-12" Extension, 5"x6" FootplatesPart: RIG152577Not available with power articulating platform.
8"-12" Extension, 5"x8" FootplatesPart: RIG152578Not available with power articulating platform.
Power Articulating Foot Platform .................. $2,995Part: PTOINDV3754. HCPCS: E1012+K0040
Manually Adjustable Center Mount Foot Platform ... $2508"-12" extension part: RIG1802138. Other extensions: RIG1710345. HCPCS: K0040
22.1. 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
No interference issues at this seat-to-floor height.
May have less than 1.75” clearance when fully extended and may interfere with the ground or reduce obstacle climbing ability.
Center Mount Foot Platform Compatibility Matrixfor TRU-Balance® 3
Power Reclineor Static Seat
Low Med. High Low Med. High Low Med. High
Power Tilt Power Lift
10”-16” Length Extension
13”-19” Length Extension
Power ArticulatingFoot Platform
22. 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.
Small Calf Pads (pair) 6”Wx6”H ....................................... $150*Part: RIGASMB7120018
Large Calf Pads (pair) 8” taper to 6”Wx8”H ....................... $150*Part: RIGASMB7120019
Small Calf Panel 18”Wx8”H ............................................. $150Part: FRMASMB7110012
Large Calf Panel 24”Wx8”H ............................................ $200Part: RIG123824Only available on widths of 20” or greater.
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.
Reversed Dartex Calf Pad Cover (pair) ............................... $150Small part: RIG133717. Large part: RIG133719
3. Center Mount Calf Support*Calf pads are standard with a power articulating foot platform. Select calf pads covers for additional charge. Calf pad and panel covers include 1/2” of soft visco foam.
4. Center Mount Modular Footplate Extension ComponentsOptional. Assembly required. May require seating configuration adjustments to avoid front caster interference.
5. Center Mount Additional Accessories
22. LEGRESTS continued
3a. Extruded Footplate(s)
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.
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
22.2. 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.
2. Lower Extension
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.
22.3. 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”
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.
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”.
3b. Swing-Away Legrest, 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”.
3c. Swing Away Legrest, Multi-Axis 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”.
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
8.5”Wx6”D Reinforced Footplate ....................... StandardPair part: FRMASMB4747. Left: RIG138060. Right: RIG138062May cause interference on seat widths less than 18.”
11”-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.
22.4. 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.
3b. 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"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.
23. SET LEGREST 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
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
Military Digital CamoPart: DGN137729-WCM7
Faded GloryPart: DGN137729-WFL2
Carbon FiberPart: DGN137729-WCB1
To Be DeterminedFollow-up required.
26. ALTERNATIVE CONTROLS AND ELECTRONICSOptional. Select a type of specialty controls below. More options are available on the Alternative Controls and Electronics order form.
26.7. 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
26.4. 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
26.3. 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 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-QIncludes 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 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 Includes module and mounting hardware.
Sip & Puff Module
26.5. 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
26.2. SCIM ModuleOptional.
26. ALTERNATIVE CONTROLS AND ELECTRONICS continued
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
27.3. 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
Install on LeftPart: PTOINDV3585
Install on RightPart: PTOINDV3586
Do Not InstallPart: PTOINDV3719
Positioning components section continued on following page.
27.1. 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.
27. POSITIONING COMPONENTSOptional. Not available with contoured seating. More options are available on the Positioning Components Order Form.
Swing-Away Joystick Mount, 18" Rod (C) .... $250 ea.Part: ST-SUS18-Q Allows mounting of facial pads and attaches to the headrest
27.6. 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
28. 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.
29. 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
ADI Q-Back, Extra Deep Contour $650 ALBR16S6Q Q-BACK,AL SERIES,EXTRA DEEP CONTOUR,16"W,16"H,(ADI)ALBR16T6Q Q-BACK,AL SERIES,EXTRA DEEP CONTOUR,16"W,18"H,(ADI)ALBR18S6Q Q-BACK,AL SERIES,EXTRA DEEP CONTOUR,18"W,16"H,(ADI)ALBR18T6Q Q-BACK,AL SERIES,EXTRA DEEP CONTOUR,18"W,18"H,(ADI)ALBR20S6Q Q-BACK,AL SERIES,EXTRA DEEP CONTOUR,20"W,16"H,(ADI)ALBR20T6Q Q-BACK,AL SERIES,EXTRA DEEP CONTOUR,20"W,18"H,(ADI)
TRU-Comfort 4-way Stretch, 20" Width or less $675 SET123622 SEAT BACK,ASSY,12"W,10"W-14"W,11"H,TRU-COMFORT 2,4 WAY STRETCHSET123623 SEAT BACK,ASSY,14"W,10"W-14"W,13"H,TRU-COMFORT 2,4 WAY STRETCHSET123631 SEAT BACK,ASSY,16"W,16"W-20"W,13"H,TRU-COMFORT 2,4 WAY STRETCHSET123633 SEAT BACK,ASSY,16"W,16"W-20"W,15"H,TRU-COMFORT 2,4 WAY STRETCHSET123635 SEAT BACK,ASSY,16"W,16"W-20"W,17"H,TRU-COMFORT 2,4 WAY STRETCHSET123637 SEAT BACK,ASSY,16"W,16"W-20"W,19"H,TRU-COMFORT 2,4 WAY STRETCHSET123639 SEAT BACK,ASSY,17"W,16"W-20"W,13"H,TRU-COMFORT 2,4 WAY STRETCHSET123641 SEAT BACK,ASSY,17"W,16"W-20"W,15"H,TRU-COMFORT 2,4 WAY STRETCHSET123651 SEAT BACK,ASSY,17"W,16"W-20"W,17"H,TRU-COMFORT 2,4 WAY STRETCHSET123653 SEAT BACK,ASSY,17"W,16"W-20"W,19"H,TRU-COMFORT 2,4 WAY STRETCHSET123655 SEAT BACK,ASSY,18"W,16"W-20"W,13"H,TRU-COMFORT 2,4 WAY STRETCHSET124576 SEAT BACK,ASSY,18"W,16"W-20"W,15"H,TRU-COMFORT 2,4 WAY STRETCHSET124578 SEAT BACK,ASSY,18"W,16"W-20"W,17"H,TRU-COMFORT 2,4 WAY STRETCHSET124597 SEAT BACK,ASSY,18"W,16"W-20"W,19"H,TRU-COMFORT 2,4 WAY STRETCH
Page 3 of 14
Section NameOption 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 3MEC140977 DOWN POST,ASSY,12"H,STRAIGHT,LEFT,TRU-BALANCE 3MEC140979 DOWN POST,ASSY,13"H-14"H,STRAIGHT,LEFT,TRU-BALANCE 3MEC140981 DOWN POST,ASSY,15"H,STRAIGHT,LEFT,TRU-BALANCE 3MEC140983 DOWN POST,ASSY,16"H,STRAIGHT,LEFT,TRU-BALANCE 3MEC140976 DOWN POST,ASSY,8"H-11"H,STRAIGHT,RIGHT,TRU-BALANCE 3MEC140978 DOWN POST,ASSY,12"H,STRAIGHT,RIGHT,TRU-BALANCE 3MEC140980 DOWN POST,ASSY,13"H-14"H,STRAIGHT,RIGHT,TRU-BALANCE 3MEC140982 DOWN POST,ASSY,15"H,STRAIGHT,RIGHT,TRU-BALANCE 3MEC140984 DOWN POST,ASSY,16"H,STRAIGHT,RIGHT,TRU-BALANCE 3MEC140410 DOWN POST,ASSY,8"H-11"H,ENDOMORPH,LEFT,TRU-BALANCE 3MEC140416 DOWN POST,ASSY,12"H,ENDOMORPH,LEFT,TRU-BALANCE 3MEC140417 DOWN POST,ASSY,13"H-14"H,ENDOMORPH,LEFT,TRU-BALANCE 3MEC140418 DOWN POST,ASSY,15"H,ENDOMORPH,LEFT,TRU-BALANCE 3MEC140419 DOWN POST,ASSY,16"H,ENDOMORPH,LEFT,TRU-BALANCE 3MEC140990 DOWN POST,ASSY,8"H-11"H,ENDOMORPH,RIGHT,TRU-BALANCE 3MEC140991 DOWN POST,ASSY,12"H,ENDOMORPH,RIGHT,TRU-BALANCE 3MEC140992 DOWN POST,ASSY,13"H-14"H,ENDOMORPH,RIGHT,TRU-BALANCE 3MEC140993 DOWN POST,ASSY,15"H,ENDOMORPH,RIGHT,TRU-BALANCE 3MEC140994 DOWN POST,ASSY,16"H,ENDOMORPH,RIGHT,TRU-BALANCE 3MEC166424 DOWN POST,ASSY,8"H-11"H,MESOMORPH,LEFT,TRU-BALANCE 3MEC166429 DOWN POST,ASSY,12"H,MESOMORPH,LEFT,TRU-BALANCE 3MEC166430 DOWN POST,ASSY,13"H-14"H,MESOMORPH,LEFT,TRU-BALANCE 3MEC166431 DOWN POST,ASSY,15"H,MESOMORPH,LEFT,TRU-BALANCE 3MEC166432 DOWN POST,ASSY,16"H,MESOMORPH,LEFT,TRU-BALANCE 3MEC166433 DOWN POST,ASSY,8"H-11"H,MESOMORPH,RIGHT,TRU-BALANCE 3MEC166435 DOWN POST,ASSY,12"H,MESOMORPH,RIGHT,TRU-BALANCE 3MEC166436 DOWN POST,ASSY,13"H-14"H,MESOMORPH,RIGHT,TRU-BALANCE 3MEC166437 DOWN POST,ASSY,15"H,MESOMORPH,RIGHT,TRU-BALANCE 3MEC166438 DOWN POST,ASSY,16"H,MESOMORPH,RIGHT,TRU-BALANCE 3
ARM134291 ARMPAD,ASSY,WATERFALL,DESK LENGTH LEFT/STRAIGHT,DESK LENGTH RIGHT COMBO,TUBE STYLE ARMREST
ARM134292 ARMPAD,ASSY,WATERFALL,DESK LENGTH RIGHT/STRAIGHT,FULL LENGTH LEFT COMBO,TUBE STYLE ARMREST
ARM134293 ARMPAD,ASSY,WATERFALL,DESK LENGTH LEFT/STRAIGHT,FULL LENGTH RIGHT COMBO,TUBE STYLE ARMREST
ARM134294 ARMPAD,ASSY,WATERFALL,FULL LENGTH RIGHT/STRAIGHT,FULL LENGTH LEFT COMBO,TUBE STYLE ARMREST
ARM134295 ARMPAD,ASSY,WATERFALL,FULL LENGTH LEFT/STRAIGHT,FULL LENGTH RIGHT COMBO,TUBE STYLE ARMREST
ARM134296 ARMPAD,ASSY,WATERFALL,FULL LENGTH RIGHT/STRAIGHT,DESK LENGTH LEFT COMBO,TUBE STYLE ARMREST
ARM134297 ARMPAD,ASSY,WATERFALL,FULL LENGTH LEFT/STRAIGHT,DESK LENGTH RIGHT COMBO,TUBE STYLE ARMREST
Single Actuator Control, Through Toggle (Power Tilt Only) No Charge ELE130021 ELECTRONIC,ASSY,Q-LOGIC/NE PLUS,THRU HIGH POWER TOGGLE,W/MANUAL RECLINE,TRU-BALANCE 3
ELE130022 ELECTRONIC,ASSY,REMOTE PLUS/Q-LOGIC//VSI/VR2/NE+/NE,THRU HIGH POWER TOGGLE,TRU-BALANCE 3
ELE1611928 ELECTRONIC,ASSY,REMOTE PLUS/Q-LOGIC//VSI/VR2/NE+/NE,THRU HIGH POWER TOGGLE,W/MANUAL RECLINE,TRU-BALANCE 3
Single Actuator Control, Through NE+ 6-Key Joystick $1,895 ELE130739 ELECTRONIC,ASSY,NE PLUS,INDEPENDENT LEGS,TRU-BALANCE 3 SEAT,(CONFIGURATION # 01)