Alternative Drive Control Order Form

Transcription

1 Customer: Contact: Type: Date: 104 John Kelly Drive, Burnet, Texas tel: fax: Chair Manufacturer Alternative Drive Control Order Form i-drive Tri-Array Bluetooth System IDHBT200-1 Tri-Array Head Support Packages Include E2330 $4, IDHBT250-1 Pediatric Tri-Array Head Support $4, Tri- Array Head Support (E0955) 3 Proximity Sensors, non-proportional, egg switch for reset mode change (E2330), and i-drive Interface * Swing-Away required to mount switch to headrest Refer to page 3 for mounting hardware selection Call Stealth Products for additional support and advanced configurations. Chair Model i-drive Pro Series Bluetooth System IDHBT300-1 Pro Series Head Support IDHBT350-1 Pediatric Pro Series Head Support Packages Include E2330 $4, $4, Occipital Pad (E0955) -B-HW Bilateral Swing-Away Hardware (E1028) Pro Series Head Support (E0955) 3 Proximity Sensors, non-proportional, egg switch for reset mode change (E2330), and i-drive Interface ** Figure 8 Bracket required to mount switch to headrest 2 Spot Pads - Choose Size: 910 3" x 2" " x 2" IDHM-CE-I Cervical Extension Inhibit Switch Reset Egg Switch Color Standard Egg Switch Color is Black. Swing-Aways -L-HW Left Side Swing-Away (E1028)** $ Additional Proximity Switches ES-BLK Black ES-BLU Blue ES-GRN Green ES-RED Red ES-YEL Yellow IDHBT501 Proximity Sensor L R L R $ B-HW Bilateral Swing-Away (E1028)** $ Figure 8 Bracket () L R $ R-HW Right Side Swing-Away (E1028)** $ ** The is included and not available for mounting additional switches or pads on the Ultra Pro only (IDHBT300-1) Figure 8 Bracket required for mounting additional switches and pads on the Ultra Pro or Tri-Array w/ swing away hardware. Reset Egg Switch Mounting None On Swing-Away Hardware Select pad to cover switch No Pad x2" 910 3x2" IDH502 Beam Sensor $ Additional Mechanical Switches IDHA-BT Bluetooth Dongle Cable MC220 Embedded MC Switch No Pad x2" 910 3x2" 920 6x2" 930 6x1.5" MC210 Tash Mini Cup Switch L R L R $ L R L R L R ARMS260 Swing-Away Armrest Mount (E1028) $ Swing-Away or Figure 8 Must be ordered for this option. Beam Sensor mounts to the back of the occipital pad. L R $ KN1ADD Knee Add. Fixed () $ ESRM Finger Egg Switch Mount () $51.45 KN1ADD-TRK Knee Add. Swing-Away w/ Track Mount () IDH503 Fiber Optic L R L R $ Select Mount for Fiber Optic FO660 Swing-Away Mount FO660 FO650 FO690 Egg Switch L R L R $80.85 ES-BLK ML210 ES-BLU ES-GRN Tash Micro-Lite Switch FO650 Pad Mount FO690 Tray Mount $ $ $ SP625 Sip & Puff for Swing-Away L ES-RED $ ES-YEL L R L R $ R L R $ Mark for: P127D138R7 5/11/2018

2 Bluetooth Tray-Array Series i-drive Control System IDTBT100-1 Proximity Sensor Tray Array* $5, GAT440 Hollow Eclipse Tray (), IDHBT500-1 i-drive Interface, GAT degree Tray Mount, 4 non-proportional proximity switch mechanisms, with egg switch for reset mode change (E2330) IDTBTF100-1 Tray Array - 3 Fiber Optic Sensor* $4, GAT440 Hollow Eclipse Tray ()IDHBT500-1 i-drive Interface, GAT degree Tray Mount, 3 fiber optic proximity switch mechanisms, with egg switch for reset mode change (E2330) * Refer to page 4 to select GAT mid line mounting system for trays. IDTBTF100-2 Tray Array - 4 Fiber Optic Sensor* $4, GAT440 Hollow Eclipse Tray ()IDHBT500-1 i-drive Interface GAT degree Tray Mount, 4 fiber optic proximity switch mechanisms, with egg switch for reset mode change (E2330) i-drive Sip & Puff Bluetooth System IDHBT210-1 Tri-Array Head Support w/ Sip & Puff $4, Tri-Array Head Support (E0955) w/ Sip & Puff, 3 Proximity Sensors, non-proportional, egg switch for reset mode change (E2330), and i-drive Interface Refer to page 3 for mounting hardware selection for head arrays. Sip & Puff Series Accessories SP625-S12 Replacement Straws - Set of 12 $32.10 SP625-S Replacement Straw for Sip & Puff $13.38 IDHBT310-1 Pro Series Head Support w/ Sip & Puff $4, Occipital Pad -B-HW Bilateral Swing-Away Hardware (E1028) Pro Series Head Support w/ Sip & Puff, 3 Proximity Sensors, non-proportional, egg switch for reset mode change (E2330), and i-drive Interface 2 Spot Pads - Choose Size: 910 3" x 2" " x 2" SP625-CT Clear Tubing for Sip & Puff $ SP625-F Replacement Sip & Puff Filter $16.05 i-connect for Manual Bases (12V) Proximity Sensor** IC12P-1 Proximity 12V w/ Single Mono Plug** $ IC12P-2 Proximity 12V w/ Dual Mono Plug** $ Fiber Optic Sensor** IC12F-1 Fiber Optic 12V w/ Single Mono Plug** $ ** Requires 12V Power Source Sip & Puff ICSNP-2 Sip & Puff w/ Dual Mono Plug $ Does NOT Require a Power Source i-connect Power Source (12V) IC12A-BC 12V Battery & Charger for i-connect $ IC12A-W 12V AC Wall Adapter for i-connect $68.00 i-connect for Power Bases (24V) Proximity Sensor IC24P-1 Proximity 24V w/ Single Mono Plug $ IC24P-2 Proximity 24V w/ Dual Mono Plug $1, Fiber Optic Sensor IC24F-1 Fiber Optic 24V w/ Single Mono Plug $ Requires 24V Power Source Sip & Puff ICSNP-2 Sip & Puff w/ Dual Mono Plug $ Does NOT Require a Power Source i-connect Power Source (24V) IC24PS-QL Power Source for Q-Logic Electronics $ IC24PS-RN Power Source for R-Net Electronics $ Mark for:

3 Precision Mini Proportional Joystick Bluetooth Precision Mini Proportional Joystick $3, Please select a topper and mounting option when ordering a joystick IDPMPBT-1-CA Castle topper IDPMPBT-1-CO Cone topper IDPMPBT-1-FT Tip topper Mounting Options SM670 Stealth PMPJ Mount for Swing-Away Hardware $ GAT486 Stealth PMPJ Mount for Gatlin $ GAT441-PMP 4" x 6.5" Center Tray w/ PMPJ Mount $ GAT441-PMP-L 4" x 6.5" Left Tray w/ PMPJ Mount $ GAT441-PMP-R 4" x 6.5" Right Tray w/ PMPJ Mount $ Environment Control Unit IDHA-ECU3 9-Pin Cable w/ 3 Mono Plugs $ IDHA-ECU4 9-Pin Cable w/ 4 Mono Plugs $ Replacement Items IDHA-BT IDHBT500 Dongle Cable - Bluetooth i-drive Bluetooth Interface $1, Select mounting option below IDHBT500-1 i-drive Bluetooth Interface, 1" Ball $1, IDHBT500-17MM i-drive Bluetooth Interface, 17mm Ball $1, Head Positioning & Headrest Hardware Mounting Hardware E1028 A B TWB480-17mm Link Style Hardware $ TWB485-17mm Link Hardware with Offset Square Tubing $ A B C C TWB480-17FDM Link Style Hardware with Flip Down $ Hardware Parts & Replacements FDM350 HMO Series Flip Down Mount $ TWB-LINK 3" (Long) Link w/ Set Screw $52.50 Sub-Occipital Pad To attach a sub-occipital pad it is required to include the SU980 and ultra mounting hardware. SU980 Ultra QCRS Adapter $ Stealth Ultra Mounting Hardware TWB480-QCRS Link Style Hrdw $ TWB485-QCR w/ Square Tubing $ TWB480-QFDM Link Hrdw w/ FDM $ Sub-Occipital Pads 600 Ultra 8" x 2.75" Medium Sub-Occipital Pad $ Ultra 10.5" x 2.75" Large Sub-Occipital Pad $53.50 i2i Sub-Occipital Pads Low Profile i2i for Sub-Occipital Pad $ I2I455 Small I2I555 Med I2I655 Lrg I2I55 XL i2i Modifications Gel Modification $ Adjustable Arms $21.40 Chin Prompt $80.25 Trachea Chin Prompt $107.00

4 Peripheral Mounts Gatlin Midline Mount 8 Position GAT400Q 3/4" Gatlin 8 Position Armrest Mount for Quantum or Quickie GAT400I GAT400P 3/4" Gatlin 8 Position Armrest Mount for Invacare 5/8" Gatlin 8 Position Armrest Mount for Permobil Invacare Electronic Mounts GAT425I Invacare Mark IV Joystick Mount GAT426I GAT427I GAT455S GAT480R GAT428I GAT429I GAT495I GAT496I GAT483 GAT491 Invacare Mark V Joystick Mount Invacare Mark VI MPJ Mount SPJ, DPJ, Mk IV-VI Mount (w/ 360 ) Invacare 1812 Joystick Mount Invacare Mark VI MPJ Mount (w/ 360 ) Invacare Mark VI PSF Mount (w/ 360 ) Invacare Display Mount (w/ 360 ) Invacare Mk VI Display Mount (w/ 360 ) ASL MEC Joystick Mount Mini ASL Joystick Mount $ ea. $ ea. 3 Position GAT405Q GAT405I GAT405P 3/4" Gatlin 3 Position Armrest Mount for Quantum or Quickie 3/4" Gatlin 3 Position Armrest Mount for Invacare 5/8" Gatlin 3 Position Armrest Mount for Permobil Quantum Electronic Mounts GAT452Q Curtis Stand Alone Joystick Mount GAT453Q GAT456Q GAT457Q GAT473Q Stand Alone Joystick Mount (w/ 360 ) Q-Logic Joystick Mount Q-Logic Joystick Mount (w/ 360 ) Quantum HMC-Compact Joystick Mount GAT495QL Q-Logic Display Swivel Mount (w/ 360 ) Permobil Electronic Mounts GAT435-RN Permobil R-Net Joystick Mount GAT458P Permobil Omni Light Mount (w/ 360 ) GAT459P Compact HMC-RN Mount (w/ 360 ) GAT472P Permobil Omni Light Mount GAT473P Permobil Compact HMC-RN Mount Gatlin Trays/Accessories GAT440 Hollow Partial Exlipse Tray (w/ 360 ) $ ea. GAT441S Solid Mini Tray (w/ 360 ) GAT440S Solid Partial Eclipse Tray (w/ 360 ) $ ea. GAT444-IP Tablet Mount (w/ 360 ) GAT441 Hollow Mini Tray (w/ 360 ) $ ea. GAT-ESM Gatlin Egg Switch Mount GAT440M-L Solid Partial Eclipse Tray w/ Mini Joystick Mount - Left Side (w/ 360 ) $ ea. GAT440M-R Solid Partial Eclipse Tray w/ Mini Joystick Mount - Right Side (w/ 360 ) $ ea. GAT441AM Solid Mini Tray w/ ASL Joystick Mount (w/ 360 ) $ ea. $ ea. $ ea. ARMS260 Swing-Away Hardware ARMS260 Swing-Away w/ Egg Switch Mount ARMS260-I Invacare Mk VI Display S/A Mount ARMS260-QL Q-Logic Display S/A Mount ARMS260-P Omni Plus Display S/A Mount TWBM480 Link Hardware TWBM480-QL Q-Logic Display Mount TWBM480-SPJ Invacare Mk VI SPJ Mount ARMS260-UNI2 Cellular Device Swing-Away Mount ARMS260-TAB Small Tablet Swing-Away Mount ARMS260-MPJ Invacare MPJ Swing-Away Mount ARMS260-MEC ASL MEC Joystick S/A Mount TWBM260-RNETVD R-Net Joystick S/A Mount TWBM480-TAB Tablet Mount TWBM480-DS Invacare SPJ, DPJ, Mk IV Mount $ ea. $ ea. $ ea. $ ea. $ ea. Mounts for Peripheral Mounts ARM250-S Height Adjustable Cane Mount for 3/4" Mounts ARM250-P Height Adjustable Flat Mount w/ Track Nuts for Permobil 5/8"Mounts ARM250-PC Height Adjustable Cane Mount for Permobil 5/8" Mounts ARM250-I Height Adjustable Cane Mount for Invacare 7/8"Mounts ARM250-3/4"FM Height Adjustable Mount w/ Flat Bracket for 3/4" Mounts ARM240-T Non-Adjustable Track Mount w/ Track Nuts for 3/4" Mounts $78.75 ea. Stealth Products, LLC. P127D138R7 5/11/2018

5 Hybrid Driving Packages IDA1H (Package 1) $5, IDA2H (Package 2) $7, The IDA1H The following: IDM-ARLITE-9 ARMS260-AR 900 PAD CP250 CPS9-B-HW TWB485-1S KN1ADD-TRK SM660-M IDAH-TBOX TWB-1 BK mo-vis All Round Joystick Lite (E2373) mo-vis Satellite Twister-Red Swing Away Joystick Mount For All Round 900 Stealth Ultra Standard Lateral Pad () Comfort Plus Medium 10in. Headrest with Back Pad with Ring Cp 1 s/a Assm Both Sides w/ Qty Rods Features 1 Ball, Square Tubing on Vertical Bar Adjustable Knee Adductor Package w/ Track Nut Swing away for IDM Allround-9 Stealth Hybrid Driving Package Tackle Box TWB-1 BK 3 Piece 1 Ball Kit for TWB480/TWB485 ARMS250-3/4 FM Height Adjustable Mount w/flat Fixed Bracket () SBM300P LPHW403 ARMS-TB3 ARMS-HW-TNP Interface Plate For Permobil CS3G Back Lateral Pelvic Universal Tracl Nut Track Nut TB3 Armrest Track Nut for Permobil CSG3 Armrest IDA3H (Package 3) $9, The IDA2H The following: IDM-ARLITE-9 mo-vis All Round Joystick Lite (E2373) mo-vis Satellite Twister-Red IDM-18 mo-vis Satellite Twister-Black ARMS260-AR Swing Away Joystick Mount For All Round CPN350 Comfort Plus nino - 6 Headrest Pad with Ring TWB485-17MM TWB485-17mm Headrest Hardware TWB-17MMBK TWB-17MMBK 3 Piece 17mmBall Kit for TWB480/TWB485 SUNS9-B-HW SUN 17mm Nino s/a Assm Both Sides w/ Qty-2 6 KN1ADD-TRK Adjustable Knee Adductor Package w/ Track Nut SM660-M Swing away for IDM Allround-9 IDAH-TBOX Stealth Hybrid Driving Package Tackle Box TWB-1 BK TWB-1 BK 3 Piece 1 Ball Kit for TWB480/TWB485 ARMS250-3/4 FM Height Adjustable Mount w/flat Fixed Bracket () SBM300P Interface Plate For Permobil CS3G Back LPHW403 Lateral Pelvic Universal Tracl Nut ARMS-TB3 Track Nut TB3 Armrest ARMS-HW-TNP Track Nut for Permobil CSG3 Armrest IDHBT Stealth Ultra Standard Lateral Pad Note: Make with long cable () IDHBT500 i-drive Bluetooth Head Control Interface The IDA3H The following: IDM-ARLITE-9 mo-vis All Round Joystick Lite (E2373) Satellite Twister Red IDM-18 Satellite Twister-Black ARMS260-AR Swing Away Joystick Mount For All Round CPN350 Comfort Plus Nino - 6 Headrest Pad with Ring TWB485-17MM TWB485-17mm Headrest Hardware IDHBT300-1 i-drive Bluetooth Stealth Pro Series 3-Proximity KN1ADD-TRK Adjustable Knee Adductor Package w/ Track Nut SM660-M Swing away for IDM Allround-9 IDAH-TBOX Stealth Hybrid Driving Package Tackle Box ARMS250-3/4 FM Height Adjustable Mount w/flat Fixed Bracket () SBM300P Interface Plate For Permobil CS3G Back LPHW403 Lateral Pelvic Universal Tracl Nut ARMS-TB3 Track Nut TB3 Armrest ARMS-HW-TNP Track Nut for Permobil CSG3 Armrest Additional Options for IDA1H Package (Package 1) Additional Options for IDA2H Package (Package 2) Additional Options for IDA3H Package (Package 3) Mark for : PO# HCPCS codes provided should not be considered as legal advice and do not guarantee reimbursement. DME providers are responsible for determining appropriate billing codes when submitting for insurance reimbursement. P127D138R7 5/11/2018