Velocity Order Form. Dealer Information Dealer Name ATP Account Number Phone Fax Date PO# Ship to Address City State Zip
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1 Fax: Velocity Order Form Dealer Information Dealer Name ATP Account Number Phone Fax Date PO# Ship to Address City State Zip Client Information Weight Height Seat-to-Floor Height Lower Leg Length Seat Depth Back Height Shoulder Width Chest Width Shoulder Height Elbow Height DME Providers are responsible for determining appropriate billing codes when submitting claims for reimbursement. HCPCS codes should not be used as legal or billing advice. 1
2 Power Base VR2 Group 3 Power base w/2 pole 275W motor (300lbs), 6mph, PG VR2-A2. Black Shroud includes lighting system Through Toggle Box (special order only) Part Number HCPCS Code MSRP Power Base R-Net Part Number HCPCS Code MSRP K0861 K0856 $7,999 - No Charge Group 3 Power base w/2 pole 275W motor (300lbs), 6mph, R-Net LED controller. Black Shroud includes lighting system R-Net Expandable Control Module K0861 K0856 $7, NI E2377 $749 P NI E2310 $1,100 R- Net Harness for Expandable Controller NI E2313 $499 Harness for Expandable Controller NI E2313 $425 R-net Joystick Assy NI E2311 $3,295 Through VR2 on power tilt / angle adjustable recline Two + Power Function through VR2 Joystick Electronics NI E2311 $2,895 The Harness and Two + Power Function are required when ordering multi-function the VR2 option. The R-Net Expandable Control Module and R-Net Harness are required when ordering the R-Net option. Deluxe Seating for VR2 Power seat, tilt / angle adjustable Part Number HCPCS Code MSRP Deluxe Seating for R-Net Part Number HCPCS Code MSRP E1002 $5,499 Power tilt / power recline R-Net seating system E1007 $10,499 Width mesured in 1" increments Width Dimensions for Tilt Only Seating Depth Base type Velocity Configuration Information VR2 base R-Net base Seat type Power Tilt only Power Tilt / Power Recline Power or Manual foot Power or Manual foot Foot platform type platform only platform, power ELRs Depth mesured in 1" increments 22 Seat elevator n/a Reserve cable connector for power footplate only optional Reserve cable for power footplate/power ELR Options Power seat lift E2300 $1,995 Joystick Brackets Inline Joystick Bracket No Charge Swing-away Bracket (Right) E1028 $ 250 Swing-away Bracket (Left) E1028 $ 250 Footplate and Legrest Options Omit Footrest / ELR option - - No Charge Standard foot platform Standard - No Charge Manual elevating legrest L & R 39904M10 E0990 $ 399 Articulating power center footplate E1012 $ 2,398 2
3 Footplate and Legrest Options Standard center footplate (W/ Calf pad) No Charge Manual elevating L &R leg rest 39904M10 E0990 $ 399 Power elevating L&R legrests E1010 $ 2,398 Power center foot platform E1012 $ 2,398 Cushion Options Omit Seat Cushion - - No Charge 16"W seat cushion $ "W seat cushion $ "W seat cushion $ "W seat cushion $ "W seat cushion $ "W seat cushion $ "W seat cushion $ 129 Backrest Options Omit Backrest - - No Charge Adapter for Comfort Company backrest and accessories) No Charge 16"W backrest cover cloth No Charge 18"W backrest cover cloth No Charge 20"W backrest cover cloth No Charge 22"W backrest cover cloth No Charge 16"W backrest No Charge 18"W backrest No Charge 20"W backrest No Charge 22"W backrest No Charge Headrest Headrest 9" E0955 $ 150 Swing-away headrest mounting hardware NI E1028 $ 99 Accessory Swing-away trunk support bracket (R&L, for one unit) E1028 $ 499 Trunk Support pad- L 6"x4"x1" (2pc/ pack) E0956 $ 79 Trunk Support pad- M 5"x4" x1" (2pc/ pack) E0956 $ 79 Trunk Support pad- S 5"x 3"x1" (2pc/ pack) E0956 $ 79 Abductor bracket E1028 $ 149 Abductor pad- M: 6"x4"x3" E0957 $ 54 Abductor pad- S: 4"x3.5"x3" E0957 $ 52 3
4 Batteries Batteries (Gel) by MK Batteries M22NF E2361 $ 319 R-Net Expandable, R-Net CJSM2 R-Net CJSM2-L-SW Power Modules R-Net Power Module 90 Amp D51109 K0108 $ Joystick Modules R-Net JSM-LED D51122 N/A $ R-Net CJSM2 BLUETOOTH (LCD Joystick Module D51634 w/ Jack Sockets, Lighting Support, N/A $ 1, R-Net cjsm2-l-sw / With lighting control and jack D51595 N/A $ 1, R-Net Attendant Module D50882 E2331 $ Mounting hardware for Attendant control module ISM-XL Seating /Lighting module with X seat channels (X=2,4,6 or 8) ISM 2 D50608 N/A $ ISM 2L D50604 N/A $ ISM 4 D50607 N/A $ ISM 4L D50603 N/A $ ISM 6 D50606 N/A $ ISM 6L D50602 N/A $ ISM 8 D51470 N/A $ Expansion Modules R-Net Omni D50881 K0108 $ 1, Mounting hardware for R-Net Omni ASL 618 R- NET K0108 $ Bluetooth Modules for Windows, Android and IDevices D51628 K0108 $ Bluetooth 1 D5111 N/A $ Bluetooth 2 D51523 N/A $ Bluetooth IOS D51580 N/A $ R-Net Accessories Battery - controller Connector D49712 K0108 $ Actuator Module D50606 K0108 $ R-Net 4-Connector Block D50829 K0108 $ R-Net Cable 0.5 Meter, M-M SA77525L05 K0108 $ R-Net Ext Cable 0.5 Meter, M-F SA78640L05 K0108 $ Optional Items R-Net programming cable SA79174 N/A $ R-Net Dongle (Dealer) D50610 N/A $ R-Net PC Programmer (Dealer) D50612 N/A $
5 Options Part HCPCS Number Code MSRP Accessories from Gel Ovations 3.5" X 12" Gel Armrests (Pair) 312G N/A $ " X 14" Gel Armrests (Pair) 314G N/A $170 Single Piece Footplate Gel Foot Protector Cover GFPCS N/A $150 Gel and Foam Calf Pad 8" X 6" X 1.5" (Pair) GCP N/A $245 Arm Troughs First Trough Side - 10"L x 2"W Right Left FTS10 N/A $100 First Trough Side - 12"L X 2"W Right Left FTS12 N/A $105 First Trough Side - 14"L X 2"W Right Left FTS14 N/A $115 Second Trough Side - 10"L X 2"W Right Left STS10 N/A $100 Second Trough Side - 12"L X 2"W Right Left STS12 N/A $105 Second Trough Side - 14"L X 2"W Right Left STS14 N/A $115 Arm trough must be ordered with 3.5" or 2" Gel Armrests 2" X 10" Gel Armrests (Pair) Right Left 210G N/A $99 2" X 12" Gel Armrests (Pair) Right Left 212G N/A $115 2" X 14" Gel Armrests (Pair) Right Left 214G N/A $130 2" Gel Armrests are only for arm troughs Universal Elbow Stop Bracket and Flat Gel Pad 3" X 4" Right Left UESF1 E2209 $107 Sta-Rite 6 Direction Adductor Bracket Flat Mount Sw Away or Rem. Right Left SRASF1 E0957 $275 Adjustable Hip Guide: SRMHG12 STUMP Bracket: 67SRSSF Adductor Bracket SRASF1 Sta-Rite Swing Away Rem. Stump Support 6" X 7.5" DSSP Flat StaRite Axis Adjustable Hip Guides 3.5" X 12" Gel Pad Right Left SRSSF E1020 $350 Right Left SRMHG12 E0956 $525 Universal Gel Elbow Stop GEL and Foam Calf GCP GEL Foot Board: GFPCS 5 UD 09/12/18
Vision Ultra-single power
Account # Dealer Name Contact Phone Date Fax E-Mail PO Number Ship to Address City State Zip *HCPCS codes provided should not be considered as legal advice and do not guarantee reimbursement. DME providers
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AADL W592/W991 Quantum Q6 Edge 2.0 with TB3 Power Positioning FOR AADL USE ONLY Pride Mobility Products Co. 5096 South Service Rd, Beamsville, ON, L0R 1B3 Phone: 888-570-1113 Fax: 866-514-1303 Discount:
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