Crystal Reports - US Order Forms 2020 Rev01.rpt
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Crystal Reports - US Order Forms 2020 Rev01.rpt
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F5 Corpus VS * Indicates a Required Field Dealer Information Order ID:______________________________ *ATP:______________________________ Dealer Code:______________________________ *Dealer Name:______________________________ Address:______________________________ *City:______________________________ * State/Zip:______________________________ * Phone#:______________________________ PO#:______________________________ Email Address:______________________________ Client Information Permobil recommends that the client is evaluated by a certified rehab specialist. * First Name:______________________________ * Last Name:______________________________ Diagnosis:______________________________ Funding Source:______________________________ Client Age:______________________________ Client Measurements * Weight:_______________________________ *Height:_______________________________ A) Top of Shoulders:_______________________________ B) Chest Depth:_______________________________ C) Chest Width:_______________________________ D) Seat Depth:_______________________________ E) Top of Head:_______________________________ F) Elbow to Hand:_______________________________ G) Seat Pan to Elbow:_______________________________ H) Hip Width:_______________________________ *I) Knee to Foot:_______________________________ Three column pricing on order/quote: Display HCPCS Codes on order/quote: Please send order/quote to fax#: (800) 231-3256 Email to: sales@permobil.com Permobil Inc. 300 Duke Dr. Lebanon, TN 37090 Tel: (800) 736-0925 Fax: (800) 231-3256 www.permobil.com Prices effective August 17, 2020 F5 Corpus VS Chair Model and Colors CHOOSE BASE: Part Number I108400-99-0 Description Price F5 Base Corpus VS - F5 MPO 18,233.00 Price Includes: FWD F5 Power Base Set Up For Multiple Power Seat Function, ComfortRide Pro Fully Independent Adjustable Suspension, ESP (Enhanced Steering Performance), Powered Support Wheels, Tie-Down Hardware for Strap Systems, Charger, Flat Free or Pneumatic Tires, a Standard Positioning Belt and Permobil Connect. Max Speed = 7.5mph, Weight Capacity = 300lbs, STFH = 17.5". CHOOSE DRIVE TIRES: Part Number I108414-99-0 I108411-99-0 I108413-99-0 Description Price Flat Free Tire 3"W x 14"T Black - Standard Tread No Charge Designed for a smooth ride on indoor and outdoor surfaces. Includes flat free standard tread caster wheels. Pneumatic Tire 3"W x 14"T Black - Standard Tread No Charge Includes flat free standard tread caster wheels. Flat Free Tire 3"W x 14"T Black - Aggressive Tread No Charge Includes flat free aggressive tread caster wheels. HCPCS Code K0884 HCPCS Code OPTIONAL DRIVE TIRES: Part Number Description Price HCPCS Code I108412-99-0 Pneumatic/Snow Tire 3"W x 14"T Black - Aggr Tread 470.00 K0108 Snow tires are designed for use in cold weather conditions. The nylon compound in these tires remains flexible at low temperatures, but wears more easily. Therefore, the snow tires (sold as wheel assemblies) are not recommended for year-long use and must be ordered along with standard drive wheels. Does not include caster wheels. CHOOSE SHROUD COLOR: Part Number I108961-99-0 I108962-99-0 I108963-99-0 I108964-99-0 I108965-99-0 I108966-99-0 I108967-99-0 I108968-99-0 I108969-99-0 I108970-99-0 I108971-99-0 I108972-99-0 I108973-99-0 I108974-99-0 I108975-99-0 I108976-99-0 I108978-99-0 I108979-99-0 I108980-99-0 I108981-99-0 Description F5 Color Kit - Aqua F5 Color Kit - Sky F5 Color Kit - Violet F5 Color Kit - Flamingo F5 Color Kit - Chili F5 Color Kit - Canary F5 Color Kit - Spring F5 Color Kit - Arctic F5 Color Kit - Sunset F5 Color Kit - Midnight F5 Color Kit - Gold F5 Color Kit - Bronze F5 Color Kit - Platinum F5 Color Kit - Carbon Fiber F5 Color Kit - Mossy Oak Break-Up Country F5 Color Kit - CDG Poly F5 Color Kit - Fireball F5 Color Kit - Water Lily F5 Color Kit - Midnight Patriot F5 Color Kit - American Liberty Price No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge HCPCS Code CHOOSE RIM COLOR: Part Number Description Price HCPCS Code Hub Cap Color: Please write in Hub Cap Color below. Hub Cap Color will be matched to the Shroud Color if no selection is made. __________________________________________________ Base Options MUST CHOOSE SEAT ELEVATOR: Part Number Description Price HCPCS Code Rev 2020-1 08/17/2020 Page 2 of 16 F5 Corpus VS Base Options MUST CHOOSE SEAT ELEVATOR: Part Number I107087-99-0 Description Active Height Power Adj. Seat Height - 14" Travel This item must be selected. Price 3,909.00 HCPCS Code E2300 SET SEAT HEIGHT: Part Number I107435-99-0 I107433-99-0 I107434-99-0 Description Price Set Seat Height to 17.5" No Charge Set Seat Height at 18.5" No Charge If ordering Power Adjustable Seat Height, 1" of elevator travel is used to set seat at 18.5". Set Seat Height at 19.5" No Charge If ordering Power Adjustable Seat Height, 2" of elevator travel is used to set seat at 19.5". HCPCS Code MUST CHOOSE BATTERIES: Part Number Description Price BATTERY OPTIONS: I108999-99-0 Permobil Batteries, Grp 24 AGM GEL, Pair 1,002.00 For maximum range. Includes Permobil VoltPro charger optimized for Permobil Batteries. HCPCS Code E2363 OPTIONAL ITEMS: Part Number I107459-99-0 I108417-99-0 I108527-99-0 I10715 I10787 I10788 ID51113 Description Price HCPCS Code Essentials Box with Reflectors 489.00 Please Note: The total backrest angle will be limited to 150� to avoid contact between backrest components and the Essentials Box. New design available Fall 2020! Essentials Box with Lights 798.00 Please Note: The total backrest angle will be limited to 150� to avoid contact between backrest components and the Essentials Box. Must also select Light Kit. New design available Fall 2020! LED Light Kit for F5 995.00 No charge with 4 power seat function configurations. Compact Laptop Ventilator Tray - Corpus Seat 1,607.00 Mounts to rear of Corpus backrest hinge. Accommodates Pulmonetic Systems / CareFusion LTV Series and similar sized Laptop Ventilators. The tray is 13"T, adjustable in width from 8" 13", and adjustable in depth from 2" - 6.5". Overall backrest angle limited to 150� when mounting this ventilator tray. Custom Option. Additional drive restrictions may apply. Battery Tray for Laptop Ventilator Tray 269.00 Measures 11 3/8" W x 6 1/2" H x 1 5/8" D. Accomodates Pulmonetic Systems Lithium-Ion Battery Pack, CareFusion SprintPack Battery System, or Richardson PowerTech Vent Power Center. Custom Option. O2 Holder for Laptop Ventilator Tray 341.00 Mounts to Left or Right Side of Laptop Vent Tray. O2 Holder is 7" Tall. Width infinitely adjustable 3.5" - 7". Depth infinitely adjustable 3.75" - 5". Custom Option. Programming Key for R-net - Permobil Version 526.00 Joystick Options CHOOSE JOYSTICK TYPE: Part Number Description Price HCPCS Code PLEASE NOTE: For additional input devices, please refer to the Alternative Drive Systems Section. I107779-99-0 Color Joystick Module, (CJSM) 1,185.00 This R-net color joystick features: A Large High-Resolution 3.5" VGA color display, control of up to 4 Bluetooth devices, Infrared control, programmable buttons and a programmable switch I107778-99-0 jack; all in a compact, durable Aluminum housing. Permobil Joystick Module 1,082.00 Designed exclusively for Permobil, this R-net color joystick features: a 2.8" color display, control of up to 4 Bluetooth devices, Infrared control, programmable buttons and a I11186 programmable switch jack; all in a compact, durable Aluminum housing. Permobil Joystick Module, NC No Charge Designed exclusively for Permobil, this R-net color joystick features: a 2.8" color display, control of up to 4 Bluetooth devices, Infrared control, programmable buttons and a programmable switch jack; all in a compact, durable Aluminum housing. Rev 2020-1 08/17/2020 Page 3 of 16 F5 Corpus VS Joystick Options CHOOSE JOYSTICK TYPE: Part Number I107829-99-0 I105700-99-0 Description Price HCPCS Code 3.5mm Y-Splitter Cable for PJSM/CJSM 36.00 K0108 For use with the PJSM or CJSM Mode/Profile jack. Allows 2 mechanical switches to control 4 separate functions. Requires PC Programming to assign the short hold and long hold commands to each switch. Switches sold separately. R-net Remote Color JS w/ Lights, Heavy Duty Gimbal 1,232.00 Heavy-Duty modification enables gimbal to hold up to extreme operating forces. Reinforced housing is attached to a standard Color LCD R-net Joystick. 3" long joystick knob has 3/4" diameter. Not compatible with alternative joystick handles. CHOOSE JOYSTICK HANDLE TYPE: Part Number I10045 I100960-99-0 I100961-99-0 I100962-99-0 I100963-99-0 I100964-99-0 I100965-99-0 I105442-99-0 I105846-99-0 I105847-99-0 I105848-99-0 Description Cone Shaped Joystick Knob - Standard Chin Cup For Joystick Knob "T" Handle For Joystick Knob "Large Ball" For Joystick Knob "Softball" For Joystick Knob "Mushroom" For Joystick Knob "Stick" For Joystick Knob 1.75" Black Foam Ball For Joystick Knob Bodypoint J/S Handle 3" U-Shaped w/ Flex-Shaft Bodypoint J/S Handle 4" U-Shaped w/ Flex-Shaft Bodypoint J/S Handle Dome Shaped, Rubber Price No Charge 127.00 179.00 127.00 167.00 167.00 167.00 127.00 167.00 167.00 167.00 HCPCS Code E2324 E2323 E2323 E2323 E2323 E2323 E2323 E2323 E2323 E2323 CHOOSE JOYSTICK MOUNT: Part Number I10664 I10665 I102537-99-0 I102538-99-0 I108037-99-0 I108038-99-0 I11232 I105210-99-0 Description Price Joystick Mount Right - Fixed No Charge Joystick Mount Left - Fixed No Charge Joystick Mount Right - Swing Away 374.00 Joystick Mount Left - Swing Away 374.00 Slimline Retractable Joystick Mount - Right 503.00 Slimline Retractable Joystick Mount - Left 503.00 Adjustable Height Panel Bracket 273.00 Provides 1.77" of vertical adjustment below the armrest and 25� of angle adjustment. Compatible with all Permobil joystick mounts except for the M1 Fixed Joystick Mount. Mount Standard Joystick on Corpus Back Hinge 344.00 Standard R-net Joystick is mounted to backrest hinge. Can be chosen instead of PN I105408-99-0. Mount on Left: _____ Mount on Right: _____ HCPCS Code E1028 E1028 E1028 E1028 E1028 OPTIONAL ITEMS: Part Number I10411 I10513 I105225-99-0 I105408-99-0 I107350-99-0 Description Price HCPCS Code Expandable Controller - R-net 699.00 E2377 This item is required when ordering power tilt, power recline, and power elevating legrests together OR when ordering an Alternative Drive Control. Harness for Expandable Controller 620.00 E2313 Must be ordered with any Expandable Controller. Co-Pilot Attendant Control R-net - Corpus 5,115.00 E2331 Attendant Control R-net 1,372.00 E2331 R-net Bluetooth iDevice Module 962.00 K0108 Allows input device commands (such as joystick nudges or switch clicks) to be used to operate an iPhone, iPad or iPod. By assigning each input to an iOS function, users can make phone calls, send texts and emails and access applications. Kit includes a Bluetooth iDevice Module, an R-net Bus Cable, and two mono jack cables for direct switch inputs (switches not included). Must be ordered with a Color JSM or Omni for mode display. Rev 2020-1 08/17/2020 Page 4 of 16 F5 Corpus VS Joystick Options OPTIONAL ITEMS: Part Number I107367-99-0 I107368-99-0 I10582 Seating System Description Price HCPCS Code R-net Bluetooth Mouse Module 962.00 K0108 Enables mouse control through any R-net input device. It can operate the mouse on a computer and on select Android devices (with R-net for Android app). Kit includes a Bluetooth Mouse Module, an R-net Bus Cable, two mono jack cables for L/R click (switches not included) and a USB BT Adapter for user's computer. Note: BT Adapter may not work with all computers. Must be ordered with a Color JSM or Omni for mode display. Add a second Bluetooth Mouse Module 962.00 K0108 Allows R-net to simultaneously pair to a second compatible computer or Android device. Each module is accessible through a separate R-net mode. Kit includes a unique Bluetooth Mouse Module, an R-net Bus Cable, two mono jack cables for L/R click and a USB BT Adapter. Output Module (IOM) for R-net Control System 1,292.00 K0108 Enables a user to control an external device (ex: Communication Device, ECU, Door Opener, etc.) through the drive input (JSM, Head Array, etc.). Each module can provide up to 4 switch closures. May require specialty cable or wiring. Up to three output modules can be installed on one wheelchair. POWER SEAT OPTIONS: Part Number Description Price I11112 Power Tilt and Power Recline - VS Seat 14,695.00 This item must be selected. Includes 50� Power Tilt & 180� Power Recline. I107029-99-0 Power Standing Function - VS Seat 7,347.00 This item must be selected. Tilt Table Stand is not available for clients over 220lbs. HCPCS Code E1007 E2301 Seating System Options CHOOSE SEAT FUNCTION CONTROL TYPE: Part Number Description Price I10585 Multiple Seat Function Control Kit for R-net 3,657.00 For operation of two or more seat functions through the wheelchair electronics via the drive control. Order with R-net electronics or remote joystick options. Please indicate below if you want push buttons or toggles on the ICS Switchbox. HCPCS Code E2311 CHOOSE PUSH BUTTONS OR TOGGLES: Part Number Description I102798-99-0 I102799-99-0 I105409-99-0 Push Buttons on ICS Switchbox (1.4m) Toggle Switches on ICS Switchbox (1.4m) Do Not Install ICS Switchbox, Send as Part Price No Charge 327.00 No Charge HCPCS Code CHOOSE MOUNTING POSITION OF ICS SWITCHBOX: Part Number Description Price HCPCS Code I10626 Mount ICS Switchbox onto R-net Joystick Bracket No Charge ICS Switchbox will be mounted to the same bracket as the R-net Joystick Module. If this item I104651-99-0 is selected, the ICS Switchbox will swing away with the Joystick Module. Mount ICS Switchbox onto Armrest No Charge Mount on Left: _____ Mount on Right: _____ I106256-99-0 Mount ICS Switchbox on Backrest 157.00 Mount on Left: _____ Mount on Right: _____ OPTIONAL ITEMS: Part Number I104196-99-0 I107088-99-0 I10750 Description Price ICS Alternative Switchbox for R-net Electronics 1,278.00 Seat function interface box that accommodates up to 8 momentary switches. Provides an additional method for accessing the seat functions. 1/8" mini-mono switches not included. Remote Stop System - F/M Series 1,264.00 Consists of a 315MHz Radio Frequency (RF) handheld transmitter and an RF receiver mounted on the wheelchair. Memory Seat Program, Corpus w/ R-net 132.00 HCPCS Code K0108 Rev 2020-1 08/17/2020 Page 5 of 16 F5 Corpus VS Seating System Options OPTIONAL ITEMS: Part Number I106209-99-0 I10898 Description Price HCPCS Code Legrest Movement Linked to Recline Electronically 50.00 Power Legrest will raise when Power Recline moves backward and will lower when back moves forward. If Power Legrest is operated, Power Recline will NOT automatically reposition. Feature works through ICS Switchbox and Driver Control. Enable Independent Repositioning Mode No Charge IRM allows for sequential movement of power seat functions into a posterior position (35� tilt, 115� recline, 135� legrest) and returns to upright position (5� tilt, 100� recline, 110� legrest). This can be accessed using a standard drive control or a single switch. On the Permobil Joystick Module, IRM is accessible through the mode/profile jack (long switch hold). Please see the Alt Drive Accessories section for switch options. Backrest Options CHOOSE FIXED OR SLIDING BACKREST KIT: Part Number I107030-99-0 I105066-99-0 Description Sliding Backrest Kit - 5" Mechanical Shear Fixed Backrest Kit - No Mechanical Shear Price No Charge 39.00 HCPCS Code CORPUS BACKREST OPTIONS: Part Number Description Price HCPCS Code BACKREST NOTE: I106532-99-0 I106533-99-0 I106534-99-0 I106535-99-0 I11107 I11108 I11109 Ergo Backs include: lateral wedges, foam lumbar pads*, UT rail mounted at the top for lateral adjustment of the headrest, and split backrest feature with height adjustment in 1" increments. Please indicate backrest height below so that a properly sized backrest cushion can be provided. Note: Backrest heights are measured from the seat pan to the top of the backrest shell with the backrest set at 90�. * Foam lumbar pads not included with Solid Backs. Corpus Ergo Back - 14"W x 23" - 28"T (C3GERGBCA) 1,095.00 E2620 Corpus Ergo Back - 16"W x 23" - 28"T (C3GERGBCA) 1,095.00 E2620 Corpus Ergo Back - 18"W x 23" - 28"T (C3GERGBCA) 1,095.00 E2620 Corpus Ergo Back - 20"W x 23" - 28"T (C3GERGBCA) 1,095.00 E2620 Solid Corpus Ergo Back - 16"W x 23" - 28"T No Charge Solid Corpus Ergo Back - 18"W x 23" - 28"T No Charge Solid Corpus Ergo Back - 20"W x 23" - 28"T No Charge . Set Corpus Backrest at 23" _____ Set Corpus Backrest at 24" _____ Set Corpus Backrest at 25" _____ Set Corpus Backrest at 26" _____ Set Corpus Backrest at 27" _____ Set Corpus Backrest at 28" _____ CORPUS BACKREST CUSHION OPTIONS: Part Number I11335 Description Leatherette Cushion - Corpus Ergo Back Price No Charge I11336 Includes Dual Density Backrest Foam. Stretch-Air Cushion - Corpus Ergo Back No Charge I11339 Includes Dual Density Backrest Foam with Stretch-Air breathable fabric cover. Foam Lumbar Pads for Solid Back - Corpus 40.00 AGILITY BACKREST OPTIONS: Part Number I11258 Description ROHO AGILITY Max Contour Direct Mount - 16" Tall Price 779.00 Backrest can be installed at a height (seat pan to top of AGILITY) between 22" and 25". I11259 Specify Shell Width (14", 16", 18", 20"W):______ ROHO AGILITY Max Contour Direct Mount - 18" Tall 779.00 Backrest can be installed at a height (seat pan to top of AGILITY) between 22" and 26". Specify Shell Width (14", 16", 18", 20"W):______ HCPCS Code HCPCS Code E2620 E2620 Rev 2020-1 08/17/2020 Page 6 of 16 F5 Corpus VS Backrest Options AGILITY BACKREST OPTIONS: Part Number Description Price I11260 ROHO AGILITY Max Contour Direct Mount - 20" Tall 779.00 Backrest can be installed at a height (seat pan to top of AGILITY) between 24" and 27". Specify Shell Width (14", 16", 18", 20"W):______ HCPCS Code E2620 Set AGILITY Backrest at 22" _____ Set AGILITY Backrest at 23" _____ Set AGILITY Backrest at 24" _____ Set AGILITY Backrest at 25" _____ Set AGILITY Backrest at 26" _____ Set AGILITY Backrest at 27" _____ CHOOSE ONE OF THE FOLLOWING: Part Number I109029-99-0 Description BodiLink Premium 3" x 5" Lateral Supports - Pair Price 425.00 HCPCS Code E0956 I109030-99-0 Must also select I109031-99-0. Includes foam wedge for additional support. Only compatible with Corpus Ergo backrest shells. BodiLink Premium 4" x 6" Lateral Supports - Pair 425.00 E0956 I109031-99-0 Must also select I109031-99-0. Includes foam wedge for additional support. Only compatible with Corpus Ergo backrest shells. Swing-Away Adj BodiLink Lateral Hdwr Corpus Pair 595.00 E1028 OPTIONAL ITEMS: Part Number I106072-99-0 Description Direct Backrest Frame - Corpus Price 510.00 HCPCS Code K0108 Used to mount ROHO Agility, Jay 3, Matrx Elite, Varilite Icon and Ride Java backrests ranging I10725 in width from 14" to 20". Slotted brackets and 1" UniTrack linkage disks provide a close, adjustable mount. Backrest pitch can be tuned by rotating the linkage disks. Some seat depth may be lost due to the position and orientation of the backrest. Split Backrest Cushion - Corpus 345.00 E2617 I10786 Custom Option. Tailored Backrest Cushion - Corpus 129.00 E2617 Sides of cushion are trimmed to provide additional clearance for lateral trunk supports. Must also select a backrest cushion (I10659 or I10660) when ordering this custom option. Seat Sizing CHOOSE SEAT WIDTH: Part Number I107023-99-0 I107024-99-0 I107025-99-0 I107026-99-0 Description Set Seat Width at 17": ____ Set Seat Width at 19": ____ Set Seat Width at 21": ____ Set Seat Width at 23": ____ Price No Charge No Charge No Charge No Charge HCPCS Code CHOOSE SEAT DEPTH: Part Number Description Price HCPCS Code PLEASE NOTE: I107013-99-0 I107014-99-0 I107015-99-0 I107016-99-0 I107017-99-0 I107018-99-0 I107019-99-0 I107020-99-0 I107021-99-0 There are three different seat depth kits, each providing three seat depth settings: (1) 14" - 16", (2) 17" - 19" and (3) 20" - 22". Please select the required seat depth and the appropriate kit will be provided. Seat Depth 14" No Charge Seat Depth 15" No Charge Seat Depth 16" No Charge Seat Depth 17" No Charge Seat Depth 18" No Charge Seat Depth 19" No Charge Seat Depth 20" No Charge Seat Depth 21" No Charge Seat Depth 22" No Charge Rev 2020-1 08/17/2020 Page 7 of 16 F5 Corpus VS Seat Sizing CHOOSE SEAT CUSHION: Part Number Description Price HCPCS Code NOTE: I11337 I11338 I10965 I11113 I11166 I11167 I11168 I11169 I11170 I11171 I107505-99-0 I11173 I105118-99-0 A Corpus II Ergonomic Seat Cushion will be provided for select seat sizes. Corpus Ergo Cushion - Leatherette Cover 578.00 E2605 Corpus Ergo Cushion - Stretch-Air Cover 578.00 E2605 Corpus Ergo Air Cushion (C3GRHOSCA) 611.00 E2622 Features ROHO Dry Floatation technology. The removable ROHO cell pad provides adjustable skin protection while the contoured foam and thigh support wedges help maintain proper positioning and stability. Includes removable stretch fabric cover. Available in widths of 17", 19" and 21" and depths of 17", 19" and 21", as well as 17" x 23". Not Available in 21" x 17" Incontinence Cover for Ergo Cushion 186.00 E2619 Made from a stretch Dartex fabric and suitable for all Ergo cushions including the Corpus Ergo Air. The cover is cut to the contours of the Ergo cushion and is designed to be used as an outer layer of protection. Cover size will be matched to cushion size. Sent as a part. ROHO QUADTRO SELECT HIGH PROFILE < 22"W 586.00 E2624 Registered in PDAC under ROHO model numbers QS98C - QS1114C. ROHO QUADTRO SELECT HIGH PROFILE > or = 22"W 628.00 E2625 Registered in PDAC under ROHO model numbers QS128C - QS1413C. ROHO HIGH PROFILE Single Comp < 22"W 586.00 E2622 Registered in PDAC under ROHO model numbers 1R98C - 1R1114C. ROHO HIGH PROFILE Single Comp > or = 22"W 628.00 E2623 Registered in PDAC under ROHO model numbers 1R138C - 1R1414C. ROHO HIGH PROFILE Sensor Ready < 22"W 586.00 E2622 Single compartment cushion designed to work with Smart Check Device I107505-99-0. Registered in PDAC under ROHO model numbers 1R98H-CA-SR - 1R1112H-CA-SR. Not available in all seat widths and depths. ROHO HIGH PROFILE Sensor Ready > or = 22"W 628.00 E2623 Single compartment cushion designed to work with Smart Check Device I107505-99-0. Registered in PDAC under ROHO model numbers 1R1310H-CA-SR - 1R1411H-CA-SR. Not available in all seat widths and depths. ROHO Smart Check Device 254.00 K0108 Sensing device that allows users to setup and maintain proper inflation pressure in ROHO Sensor Ready cushions. Only available when ordered with a ROHO Sensor Ready cushion. Incontinence Cover for ROHO Cushion 161.00 E2619 Made from a stretch Dartex fabric and suitable for all ROHO seat cushions. Cover size will be matched to the cushion size. Sent as a part. Omit Seat Cushion No Charge Armrest Options CHOOSE ARMBAR KIT AND MOUNTING POSITION: Part Number Description Price HCPCS Code PLEASE NOTE: I106543-99-0 I106544-99-0 Narrow Armbar Kit can be adjusted from 15"W to 19"W between the armrest pads without any addtional parts. Wide Armbar Kit can be adjusted from 19"W to 23"W between the armrest pads without any additional parts. Please select both Armbar Kit and Width Setting below. Narrow Armbar Kit, Inf Adjustable 15"W - 19"W No Charge Wide Armrest Kit, Inf Adjustable 19"W - 23"W No Charge Required when selecting a 20" wide backrest. Set the Width Between the Armrests to: _____ Must be wider than backrest width to ensure proper fit. Please round to nearest 1". CHOOSE ARMREST HEIGHT MOUNTING POSITION: Part Number Description I105069-99-0 Height Adjustable Armrests - NC No charge when ordering power tilt and/or recline. Price No Charge HCPCS Code Rev 2020-1 08/17/2020 Page 8 of 16 F5 Corpus VS Armrest Options CHOOSE ARMREST HEIGHT MOUNTING POSITION: Part Number Description Price HCPCS Code SET ARMREST HEIGHT AT:_____ Corpus VS Armrests are infinitely adjustable from 9" - 15", measured from the seat pan to the top of the arrmrest pad. No additional parts are needed to get this full range of adjustment. In one inch increments (ex: 9", 10", etc.), please indicate where you would like the armrests set. CHOOSE ARMREST PAD RIGHT: Part Number I105100-99-0 I105104-99-0 I105105-99-0 I105999-99-0 I107212-99-0 I106047-99-0 I107214-99-0 I105995-99-0 I107591-99-0 I107593-99-0 I107595-99-0 I107597-99-0 Description 4"x10" Corpus Armrest Pad Right - Leatherette 4"x13" Corpus Armrest Pad Right - Leatherette 4"x16" Corpus Armrest Pad Right - Leatherette 4"x18" Corpus HD Armrest Pad Right - Leatherette 4"x10" Corpus Armrest Pad Right - Black Fabric 4"x13" Corpus Armrest Pad Right - Black Fabric 4"x16" Corpus Armrest Pad Right - Black Fabric 4"x18" Corpus HD Armrest Pad Right - Black Fabric 4"x10" Corpus Arm w/ Permobil Gel Pad - Right 4"x13" Corpus Arm w/ Permobil Gel Pad - Right 4"x16" Corpus Arm w/ Permobil Gel Pad - Right 4"x18" Corpus HD Arm w/ Permobil Gel Pad - Right Price No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge 175.00 180.00 185.00 190.00 HCPCS Code CHOOSE ARMREST PAD LEFT: Part Number I105098-99-0 I105102-99-0 I105107-99-0 I105998-99-0 I107213-99-0 I106046-99-0 I107215-99-0 I105994-99-0 I107590-99-0 I107592-99-0 I107594-99-0 I107596-99-0 Description 4"x10" Corpus Armrest Pad Left - Leatherette 4"x13" Corpus Armrest Pad Left - Leatherette 4"x16" Corpus Armrest Pad Left - Leatherette 4"x18" Corpus HD Armrest Pad Left - Leatherette 4"x10" Corpus Armrest Pad Left - Black Fabric 4"x13" Corpus Armrest Pad Left - Black Fabric 4"x16" Corpus Armrest Pad Left - Black Fabric 4"x18" Corpus HD Armrest Pad Left - Black Fabric 4"x10" Corpus Arm w/ Permobil Gel Pad - Left 4"x13" Corpus Arm w/ Permobil Gel Pad - Left 4"x16" Corpus Arm w/ Permobil Gel Pad - Left 4"x18" Corpus HD Arm w/ Permobil Gel Pad - Left Price No Charge No Charge No Charge No Charge No Charge No Charge No Charge No Charge 175.00 180.00 185.00 190.00 HCPCS Code MUST CHOOSE CHEST SUPPORT AND HARDWARE: Part Number I107177-99-0 I107176-99-0 I107175-99-0 I107174-99-0 I107203-99-0 Description Chest Support Small - 10"W x 5.75"T Must select Fixed or Adj Removable Hardware below. Chest Support Medium - 12"W x 5.75"T Must select Fixed or Adj Removable Hardware below. Chest Support Large - 14"W x 5.75"T Must select Fixed or Adj Removable Hardware below. Fixed Chest Support Hardware Adj Removable Chest Support Hardware Price 301.00 324.00 334.00 No Charge 282.00 HCPCS Code E1028 OPTIONAL ITEMS: Part Number I107339-99-0 I107338-99-0 I107840-99-0 I107863-99-0 Description Armrest Pouch - Right Armrest Pouch - Left UT Armrest Side Support - Right Outer Includes 2"T x 6.5"W tapered pad. UT Armrest Side Support - Left Outer Includes 2"T x 6.5"W tapered pad. Price 244.00 244.00 352.00 352.00 HCPCS Code Rev 2020-1 08/17/2020 Page 9 of 16 F5 Corpus VS Armrest Options OPTIONAL ITEMS: Part Number I107864-99-0 I107865-99-0 I107839-99-0 I107838-99-0 I10881 I10882 Legrest Options Description Price HCPCS Code UT Armrest Side Support - Right Inner 352.00 Includes 2"T x 6.5"W tapered pad. May require an increase to the width between the armrests to ensure armrests will flip-up. UT Armrest Side Support - Left Inner 352.00 Includes 2"T x 6.5"W tapered pad. May require an increase to the width between the armrests to ensure armrests will flip-up. UT Elbow Support - Right 174.00 K0108 Must also select PN I10881. UT Elbow Support - Left 174.00 K0108 Must also select PN I10882. Adjustable Elbow Support Hardware - Right 256.00 Adjustable Elbow Support Hardware - Left 256.00 CORPUS VS LEGREST AND KNEE SUPPORT: Part Number Description Price I107760-99-0 Corpus VS Power Legrest Elevation - 180� 3,756.00 Includes power articulation. I106965-99-0 Corpus VS Stand and Drive Package 1,306.00 Includes Powered Support Wheel, which are required for safe operation of the chair for both I107038-99-0 the stand and stand and drive operation. Knee Support/Abductor - Corpus VS 267.00 Select when ordering Corpus VS Legrest. Must also select I11129. I11129 Adj Removable Knee Support Hardware (1 Each) 280.00 . CHOOSE FOOTPLATE STYLE: Part Number Description I106969-99-0 I106971-99-0 I106967-99-0 1pc Corpus VS Footplate - 9"D x 16.5"W 2pc Wide Corpus VS Footplates - 9"D x 7.5"W 2pc Narrow Corpus VS Footplates - 9"D x 6"W Price No Charge 289.00 289.00 . HCPCS Code E1012,K0108 K0108 E0957 HCPCS Code K0108 FOOTPLATE HEIGHT POSITION: Part Number Description Price SET FOOTPLATE HEIGHT AT:____ This is measured from the SEAT PAN to the top of the FOOTPLATE, when the legrest assembly is at 90�. DO NOT INCLUDE CUSHION THICKNESS IN YOUR MEASUREMENT. In one inch increments, please indicate desired footplate height. NOTE: Corpus footplate height range is 6"-17" and Corpus VS height range is 9"-17". Height may need to be reduced for shipping. Calf Pads are not available at heights less than 9". OPTIONAL ITEMS: Part Number I107211-99-0 I106190-99-0 I106188-99-0 I106186-99-0 I106530-99-0 I106225-99-0 Description VS Calf Support Kit (J) w Mesh Cover & Adj Hardware 5"W x 6.5"T Pad. Compatible with footplate heights of 10" - 18". VS Calf Support Kit (A) w Mesh Cover & Adj Hardware 5.5"W x 6"T Pad. Compatible with footplate heights of 10" - 18". VS Calf Support Kit (H) w Mesh Cover & Adj Hardware 7"W x 7"T Curved Pad. Compatible with footplate heights of 11" - 18". VS Calf Support Kit (D) w Mesh Cover & Adj Hardware 8"W x 8"T Pad. Compatible with footplate heights of 12" - 18". Stealth Gel Pads - Narrow Footplates (Pair) Stealth Gel Pads - Wide Footplates (Pair) Price No Charge No Charge 378.00 378.00 430.00 440.00 Accessories I104518-99-0 Bodypoint Non-Padded Hip Belt - Medium No Charge HCPCS Code HCPCS Code Rev 2020-1 08/17/2020 Page 10 of 16 F5 Corpus VS Accessories MUST CHOOSE POSITIONING BELT: Part Number I104520-99-0 I104514-99-0 I104516-99-0 I108267-99-0 I108266-99-0 Description Bodypoint Padded Hip Belt - Medium Bodypoint Non-Padded Hip Belt - Large Bodypoint Padded Hip Belt - Large Bodypoint Padded Hip Belt "Airplane" Latch - Med Bodypoint Padded Hip Belt "Airplane" Latch - Large Price 153.00 130.00 204.00 205.00 215.00 HCPCS Code HEADREST OPTIONS: Part Number I107470-99-0 Description Permobil 7"W Headrest w/ Link Hardware Price 397.00 HCPCS Code E0955 I107469-99-0 Must also select I107480-99-0 or I107481-99-0. Permobil 10"W Headrest w/ Link Hardware 397.00 E0955 I107468-99-0 Must also select I107480-99-0 or I107481-99-0. Permobil 14"W Headrest w/ Link Hardware 397.00 E0955 I107480-99-0 I108721-99-0 Must also select I107480-99-0 or I107481-99-0. Adj/Removable Headrest Link Hardware - Standard Adj/Removable BodiLink Head Support Hdwr - MAX 8 273.00 330.00 E1028 E1028 I11305 Must be selected when ordering more than 2 swing-away headrest accessories or chin boom assemblies. Swing Away Egg Switch Assembly 586.00 E1028 I11306 Mount on Upper Left:____ Mount on Upper Right:_____ Swing Away Microlight Assembly 668.00 E1028 I11307 Mount on Upper Left:____ Mount on Upper Right:_____ Swing Away Facial Pad Assembly 4"L x 2"T 475.00 E1028 I11308 Mount on Upper Left:____ Mount on Upper Right:_____ Swing Away Facial Pad Assembly 6"L x 2"T 475.00 E1028 I11276 Mount on Upper Left:____ Mount on Upper Right:_____ Provide Headrest Receiver for AGILITY Backrest No Charge I106331-99-0 Select for AGILITY backs and third party backs ordered off chair. Permobil 10"W Headrest, Leatherette 363.00 E0955 I10552 I107499-99-0 Not available with ROHO AGILITY Back Systems. Must also select PN I10552. Adj/Removable Headrest Hardware 280.00 Universal Headrest Adapter 276.00 E1028 Please Note: Recline is limited to 160� or less (depending on backrest height) when ordering a Universal Headrest Adapter on a 23" or 24" tall Corpus backrest. OPTIONAL ITEMS: Part Number I109040-99-0 Description BodiLink Premium LPTS Pad (B), Stretch-Air - Pair Price 325.00 HCPCS Code E0953 I109043-99-0 4.5"W x 3.5"T Pad w/additional foam insert and Stretch-Air cover. Must also select BodiLink LPTS Mounting Hardware. BodiLink Premium LPTS Pad (A), Stretch-Air - Pair 325.00 E0953 6"W x 5.5"T Pad w/additional foam insert and Stretch-Air cover. Must also select BodiLink I109041-99-0 LPTS Mounting Hardware. BodiLink Premium LPTS Pad (C), Stretch-Air - Pair 325.00 E0953 I109042-99-0 8"W x 3.5"T Pad w/additional foam insert and Stretch-Air cover. Must also select BodiLink LPTS Mounting Hardware. BodiLink Premium LPTS Pad (G), Stretch-Air - Pair 325.00 E0953 I109044-99-0 12"W x 3.5"T Pad w/additional foam insert and Stretch-Air cover. Must also select BodiLink LPTS Mounting Hardware. Adj/Removable BodiLink LTPS Hdwr Med Corpus Pair 625.00 E1028 I109194-99-0 I105260-99-0 I105292-99-0 I106210-99-0 Medium TT Power Mount hardware can be extended upward to clear cushions of 3-5.5" thick. Adj/Removable Lateral Thigh/Hip Hardware - Pair 551.00 E1028 Transfer Handles, Corpus Seat 503.00 K0108 Push Handles, Corpus Seat 447.00 RAM Self-Leveling Cup Holder 85.00 Rev 2020-1 08/17/2020 Page 11 of 16 F5 Corpus VS Accessories OPTIONAL ITEMS: Part Number I106806-99-0 I107100-99-0 I107222-99-0 I105805-99-0 I102059-99-0 I105840-99-0 I105839-99-0 I105850-99-0 I10843 I10556 I108231-99-0 I108230-99-0 I108228-99-0 I108227-99-0 I108229-99-0 I108232-99-0 I108233-99-0 I105224-99-0 I105223-99-0 Description Price HCPCS Code RAM X-Grip Phone Holder 85.00 RAM X-Grip 10" Tablet Holder w/Swing Away Mount 427.00 Compatible with most 10" screen tablets with or without a protective case. Includes adjustable swing away mount (I103476-99-0). Customization may be required if ordered with an Omni. USB Charger 212.00 Provides up to 1.5A (at 5V) to charge most smartphones and tablets. The charger features an isolated circuit design for improved safety; and by pulling power from the ICS, prevents battery drainage when the chair is powered off. Includes mounting hardware and ICS connector. No charge with 4 power seat function configurations. Mount on left armrest: _____ Mount on right armrest: _____ Medical Necessities Bag Hooks 101.00 K0108 Please Note: Recline is limited to 165� or less (depending on backrest height) when ordered with 23" or 24" tall Ergo backrest. Custom required if ordered with a ROHO AGILITY backrest. May ship as a part at shorter backrest heights. Medical Necessities Bag 293.00 Includes hardware to attach bag to backrest. Please Note: Recline is limited to 165� or less (depending on backrest height) when ordering with a 23" or 24" tall Ergo backrest. Custom required if ordered with a ROHO AGILITY backrest. Bodypoint Monoflex Medium Chest Support Belt Kit 187.00 E0960 18.25"L x 4"W Pad Size. Item will be shipped as a part. Bodypoint Monoflex Large Chest Support Belt Kit 187.00 E0960 21.5"L x 4.5"W Pad Size. Item will be shipped as a part. Bodypoint Monoflex X-Lrge Chest Support Belt Kit 187.00 E0960 24.5"L x 5"W Pad Size. Item will be shipped as a part. Small Angle Adjustable Tray 309.00 E0950 Must also select PN I10556. Mount on Left: _____ Mount on Right: _____ Adj Removable - Tray Hardware (1 Each) 280.00 Permobil Adjustable Tray - 11"W 260.00 E0950 Permobil Adjustable Tray - 13"W 260.00 E0950 Permobil Adjustable Tray - 15"W 260.00 E0950 Permobil Adjustable Tray - 17"W 260.00 E0950 Permobil Adjustable Tray - 19"W 260.00 E0950 Permobil Tray Hardware Right Side Adjustable 190.00 Permobil Tray Hardware Left Side Adjustable 190.00 Oxygen Holder, Corpus 275.00 Crutch Holder, Corpus 275.00 E2207 Alternative Drive Systems ALTERNATIVE PROPORTIONAL JOYSTICK SYSTEMS: Part Number I10751 Description Mini-Joystick for Omni - (9-pin connector) Price 3,314.00 HCPCS Code E2312 I103893-99-0 Operating Force = 0.5 oz (13 g) Neutral to Full Deflection = 0.2" (5mm) Compact Joystick for Omni - (9-pin connector) 1,621.00 E2373 Operating Force = 7.8 oz (220 g) Neutral to Full Deflection = 1.1" (28mm) Joystick includes two 1/8" mono jacks for Mode and On/Off. Includes Standard Joystick Knob and 1.75" (42mm) I103894-99-0 Foam Ball Knob. Compact Joystick LITE for Omni - (9-pin connector) 1,834.00 E2373 Operating Force = 1.8 oz (50 g) Neutral to Full Deflection = 0.7" (17mm) Joystick includes two 1/8" mono jacks for Mode and On/Off. Includes Standard Joystick Knob and 1.75" (42mm) Foam Ball Knob. ALT PROPORTIONAL JOYSTICK MOUNTING HARDWARE: Part Number Description Price HCPCS Code Rev 2020-1 08/17/2020 Page 12 of 16 F5 Corpus VS Alternative Drive Systems ALT PROPORTIONAL JOYSTICK MOUNTING HARDWARE: Part Number Description Price HCPCS Code NOTE: I107946-99-0 I107948-99-0 I107857-99-0 I107947-99-0 I104690-99-0 Please see the PERMOfix Mounting Solutions, within the Alt Drive Accessories section, for additional mounting options. The Swing Away Chin Boom Assemblies are Compatible with Permobil Headrests I107470-99-0, I107469-99-0 or I107468-99-0 and must be selected with I108721-99-0. Swing Away Chin Boom Assm for Compact Lite - Left 425.00 Swing Away Chin Boom Assm for Compact Lite - Right 425.00 Swing Away Chin Boom Assm for Mini Joystick - Left 425.00 Swing Away Chin Boom Assm for Mini Joystick - Right 425.00 Alt JS Swing Away Mount Kit - Armrest 284.00 E1028 E1028 E1028 E1028 E1028 I107135-99-0 Mount in front of Left Arm: _____ Mount in front of Right Arm: _____ Alt JS / Omni Combo Swing Away Mount Kit - Armrest 537.00 E1028 Used to mount Omni and Alternative Proportional Joystick to the same armrest. Includes Swing Away Omni/Tablet Mount, with a longer mounting rod, two PERMOfix modules, one 3" rod and one 4" rod. I104143-99-0 Mount in front of Left Arm: _____ Mount in front of Right Arm:_____ Alt JS Adjustable Mount Kit - Chin Boom 885.00 E1028 I10752 Swing-Away / Removable Chin Boom mounted on right of backrest shell. Custom charge may be applied if ordering lower backrest heights. Haims Harness for Chin Control Mount, Large 629.00 E1028 I10753 For neck width up to 7�". Haims Harness for Chin Control Mount, Small 629.00 E1028 For neck width up to 5�". ALT PROPORTIONAL JOYSTICK ACCESSORIES: Part Number I104904-99-0 Description Dual Switches for Compact Joystick - Fixed Mount Price 263.00 HCPCS Code I104641-99-0 Includes two pushbutton switches mounted on rigid arms. Switches set-up for Mode & On/Off function. Switch operation force = 4.5oz (130 g) Mount at front of Joystick: _____ Mount at rear of Joystick: _____ Mount at left of Joystick: _____ Mount at right of Joystick: _____ Dual Switches for Compact Joystick -Gooseneck Mount 474.00 Includes two pushbutton switches mounted on adjustable gooseneck arms. Switches are positioned on Left and Right sides of Compact Joystick. Switches set-up for Mode & On/Off function. Switch operation force = 4.5oz (130 g) SIP & PUFF SYSTEMS: Part Number I10573 Description Sip & Puff System for Omni Price 1,773.00 HCPCS Code E2325,E2326 I10574 Requires Omni Control Module. Includes breath tube kit. Sip & Puff System with Fiber Optic Opti-Stop 2,360.00 E2325,E2326 I106807-99-0 Requires Omni Control Module. Includes breath tube kit. Sip & Puff Kit for Total Control Head Array 914.00 E2325 I10762 For use with Total Control Head Array. Requires Omni Control Module. Includes breath tube kit. Adjustable Mounting Hrdw - Sip & Puff 284.00 Required when selecting PN I10573, I10574 or I106807-99-0. Total Control Head Array CONFIGURE HEAD ARRAY: Part Number Description Price I106805-99-0 Permobil Head Array - 3-Switch System 4,893.00 Features an occipital pad sensor and two stainless steel arms configured with proximity sensors. The arms are mounted to the upper attachment points on the head array. Longer arms are also included to extend the sensor adjustment range. ESP recommended. Choose Omni Control Module separately. HCPCS Code E2330 Rev 2020-1 08/17/2020 Page 13 of 16 F5 Corpus VS Total Control Head Array CONFIGURE HEAD ARRAY: Part Number Description Price I11072 Program Head Array as a 5-Switch System No Charge Select additional arms/sensors below and indicate the intended use of each sensor in the Notes & Comments section. Choose Omni Control Module separately. HCPCS Code I105920-99-0 I105921-99-0 I10847 I105936-99-0 CHOOSE OCCIPITAL PAD SIZE (REQUIRED): Small Occipital Pad for Head Array - 4.25"W x 3"H No Charge Large Occipital Pad for Head Array - 6"W x 4"H No Charge . CHOOSE OCCIPITAL MOUNT (REQUIRED): Fixed Mount for Head Array Occipital Pad No Charge Adj. Swivel Mount for Head Array Occipital Pad 439.00 Enables Occipital Pad to be angled up/down and left/right independent of the lateral arms. K0108 I105927-99-0 I105941-99-0 I105925-99-0 I10976 I10977 I10978 CHOOSE HEAD ARRAY MOUNT HARDWARE (REQUIRED): Stealth TWB480 Backrest Mounting Hdwr with Links Please select the length of the vertical stem below: Standard length (10"): _____ Short length (6"): _____ Stealth TWB480 Backrest Mnt Hdwr with Flipback Stealth HMO475 MultiAxis Backrest Mounting Hdwr SELECT ADDITIONAL LEFT ARM PACKAGE (OPTIONAL): Add Left Lateral Arm w Proximity Sensor Choose Lateral Arm Adjustment Range: Short (5.5" - 10"): ______ Long (5.5" - 14"): ______ Add Left Lateral Arm w Egg Switch Choose Lateral Arm Adjustment Range: Short (5.5" - 10"): ______ Long (5.5" - 14"): ______ Add Left Lateral Arm w Pad (No Sensor or Switch) Choose Lateral Arm Adjustment Range: Short (5.5" - 10"): ______ Long (5.5" - 14"): ______ 293.00 E1028 473.00 260.00 630.00 E1028 E1028 515.00 420.00 I10979 I10980 I10981 SELECT ADDITIONAL RIGHT ARM PACKAGE (OPTIONAL): Add Right Lateral Arm w Proximity Sensor Choose Lateral Arm Adjustment Range: Short (5.5" - 10"): ______ Long (5.5" - 14"): ______ Add Right Lateral Arm w Egg Switch Choose Lateral Arm Adjustment Range: Short (5.5" - 10"): ______ Long (5.5" - 14"): ______ Add Right Lateral Arm w Pad (No Sensor or Switch) Choose Lateral Arm Adjustment Range: Short (5.5" - 10"): ______ Long (5.5" - 14"): ______ Alt Drive Systems Setup 630.00 515.00 420.00 CHOOSE OMNI (REQUIRED): Part Number Description Price HCPCS Code I108500-99-0 Omni2 Control Module for R-net - Corpus 1,887.00 Two-section design features 3.5" VGA high resolution display, USB charger port, built in IR control and integrated Bluetooth technology for control of up to 4 Bluetooth devices. Must also select mounting hardware below. Please specify which type of alternative drive input device I103476-99-0 you will be using. Input Device:______________________________ Adjustable Swing-Away Hardware - Omni/Tablet 284.00 Mount in front of Left Arm: _____ Mount in front of Right Arm: _____ CHOOSE MOUNTING POSITION OF SEAT CONTROL SWITCHBOX: Part Number Description I10080 Mount Seat Control Switchbox on Backrest Alt Drive Accessories Price No Charge HCPCS Code Rev 2020-1 08/17/2020 Page 14 of 16 F5 Corpus VS Alt Drive Accessories PERMOFIX MOUNTING SOLUTIONS: Part Number I106655-99-0 Description PERMOfix UniTrack Fixed Mount Kit Price 286.00 HCPCS Code I106656-99-0 Includes two base joints, two 4" rods and one 8" rod. PERMOfix UniTrack Removable Mount Kit 502.00 Includes quick release mount and thigh support hardware, two base joints and three different I106657-99-0 length rods. PERMOfix UniTrack Swing Away Mount Kit 719.00 I105907-99-0 Includes PERMOfix Swing Away module, two base joints, one 2" rod and one 4" rod. Proximity Sensor + Swivel Assembly 363.00 E1028 I105919-99-0 Only available with the Total Control Head Array. Swivel assembly allows sensor to be mounted with PERMOfix or directly to lateral arm of Total Control Head Array. Since Proximity Sensors require power, they CANNOT be used as On/Off switches. Egg Switch + Swivel Mount Assembly 245.00 Swivel assembly allows switch to be mounted with PERMOfix or directly to lateral arm of Total I105912-99-0 Control Head Array. Solid Oval Pad + Swivel Assembly 148.00 I106675-99-0 Swivel assembly allows pad to be mounted with PERMOfix or directly to lateral arm of Total Control Head Array. Oval Plate + Swivel Assembly - No Switch 130.00 Blank plate provides mounting option for Micro Lite, Buddy Button or other switch options. Swivel assembly allows pad to be mounted with PERMOfix or directly to lateral arm of Total Control Head Array. OPTIONAL ITEMS: Part Number I101769-99-0 I101767-99-0 I106293-99-0 I101771-99-0 I107500-99-0 I107495-99-0 I10772 Description Microlight Switch Qty:____ Buddy Button Qty:____ Egg Switch Black Qty: _____ Mini Cup Switch Qty:____ Proximity Switch Qty:____ Mini Joyswitch 5 Switch OC for Omni - (9-pin) Dome Switch, Backrest Mnt w Gooseneck Qty: _____ Price 198.00 167.00 167.00 167.00 662.00 718.00 524.00 HCPCS Code Mount on Left: _____ Mount on Right: _____ Mounts at top of backrest shell. Custom charge may be applied if ordering with short backrest heights Kit Includes: One PERMOfix joint with Flat Plate, two PERMOfix joints with 45� swivel adjustment, one 6" rod, one 8" rod and one 9" gooseneck switch with 50" cable and mounting I10846 clamp. Dome Switch, Backrest Swg Awy Mnt w Gsneck Qty:____ 775.00 K0108 I105935-99-0 I105931-99-0 I105932-99-0 I105933-99-0 I105934-99-0 Mount on Left: _____ Mount on Right: _____ w 90� Swing-Away Function. Mounts at top of back. Custom charge applies if ordered with short back. Kit Includes: One PERMOfix joint with Flat Plate, one PERMOfix joint with 45� swivel adjustment, two 6" rods, one 90� Swing-Away joint, one 9" gooseneck switch w 50" cable and mounting clamp. 3.5mm Ext. Cable for Sensor/Switch, 0.3m Long 33.00 3.5mm Ext. Cable for Sensor/Switch, 1m Long 36.00 3.5mm Ext. Cable for Sensor/Switch, 2m Long 42.00 3.5mm Ext. Cable for Sensor/Switch, 3m Long 46.00 3.5mm Y-splitter Cable for Sensor/Switch 36.00 Allows two Proximity Sensors/Mechanical Switches to connect to the same direction jack. Rev 2020-1 08/17/2020 Page 15 of 16 Additional Order Instructions (for Permobil): Notes & Comments (not for Permobil): Chair Order Policy: You are highly encouraged to contact Permobil Sales with ANY questions regarding proper completion of our order forms at 1-800-736-0925. The order cannot be processed without the following: -A client name or code, the client's measurements, the client's weight -The order form must also be signed by a person authorized by your company to acknowledge the items selected. Permobil, Inc. is not responsible for configuration or size discrepancies resulting from customer errors on the order form. -Order confirmations will be provided by Permobil summarizing the items selected. Please review this carefully. -Once the order is shipped, any changes are subject to the returns policy and may be prohibited. Order Acknowledgement: I, _________________________, am an agent of the medical equipment provider named on this order form and I have the authority to contract for the purchase of powered wheelchairs and related parts on behalf of said provider. I acknowledge that I have reviewed this order and that it is complete and accurate to the best of my knowledge. I further acknowledge that any changes to this order after submission of this order form are subject to the returns policy and may carry additional charges. Signed: Printed Name: Title: Date: NOTE: All specifications and prices are subject to change without notice. Please note that prices displayed are only valid if ordered with the wheelchair. Any parts ordered for service or future alterations will carry different pricing and warranty. The HCPCS codes provided are not intended to be billing or legal advice, rather our interpretation of the code definitions. Use of the codes does not ensure coverage or payment for the item. For coverage information, verify the policy of the appropriate payer. Rev 2020-1 08/17/2020 Page 16 of 16