1-800-963-7487 Fax: 239-772-3252 Velocity Order Form Dealer Information Dealer Name ATP Account Number Phone Fax E-Mail 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
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 30200553 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 30200554 K0861 K0856 $7,999 64220012-NI E2377 $749 P3230001-NI E2310 $1,100 R- Net Harness for Expandable Controller 63370444-NI E2313 $499 Harness for Expandable Controller 63370435-NI E2313 $425 R-net Joystick Assy 33500325-NI E2311 $3,295 Through VR2 on power tilt / angle adjustable recline Two + Power Function through VR2 Joystick Electronics 33500524-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 32200533 E1002 $5,499 Power tilt / power recline R-Net seating system 32200528 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 16 17 16 17 Seat type Power Tilt only Power Tilt / Power Recline 18 19 18 19 Power or Manual foot Power or Manual foot Foot platform type platform only platform, power ELRs 20 21 Depth mesured in 1" 20 21 22 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 32100255 E2300 $1,995 Joystick Brackets Inline Joystick Bracket 39922020 - No Charge Swing-away Bracket (Right) 39922019 E1028 $ 250 Swing-away Bracket (Left) 39922020 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 33300418 E1012 $ 2,398 2
Footplate and Legrest Options Standard center footplate (W/ Calf pad) 33300425 - No Charge Manual elevating L &R leg rest 39904M10 E0990 $ 399 Power elevating L&R legrests 33400296 E1010 $ 2,398 Power center foot platform 33300418 E1012 $ 2,398 Cushion Options Omit Seat Cushion - - No Charge 16"W seat cushion 39922023 - $ 129 18"W seat cushion 39922025 - $ 129 20"W seat cushion 39922026 - $ 129 16"W seat cushion 43780125 - $ 129 18"W seat cushion 43780111 - $ 129 20"W seat cushion 43780126 - $ 129 22"W seat cushion 43780191 - $ 129 Backrest Options Omit Backrest - - No Charge Adapter for Comfort Company backrest and accessories) 39900210 - No Charge 16"W backrest cover cloth 43780129 - No Charge 18"W backrest cover cloth 43780113 - No Charge 20"W backrest cover cloth 43780130 - No Charge 22"W backrest cover cloth 43780194 - No Charge 16"W backrest 43780127 - No Charge 18"W backrest 43780112 - No Charge 20"W backrest 43780128 - No Charge 22"W backrest 43780193 - No Charge Headrest Headrest 9" 39906011 E0955 $ 150 Swing-away headrest mounting hardware 32100238 - NI E1028 $ 99 Accessory Swing-away trunk support bracket (R&L, for one unit) 39900179 E1028 $ 499 Trunk Support pad- L 6"x4"x1" (2pc/ pack) 39900191 E0956 $ 79 Trunk Support pad- M 5"x4" x1" (2pc/ pack) 39900177 E0956 $ 79 Trunk Support pad- S 5"x 3"x1" (2pc/ pack) 39900178 E0956 $ 79 Abductor bracket 39900176 E1028 $ 149 Abductor pad- M: 6"x4"x3" 39900174 E0957 $ 54 Abductor pad- S: 4"x3.5"x3" 39900175 E0957 $ 52 3
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 $ 899.00 Joystick Modules R-Net JSM-LED D51122 N/A $ 899.00 R-Net CJSM2 BLUETOOTH (LCD Joystick Module D51634 w/ Jack Sockets, Lighting Support, N/A $ 1,199.00 R-Net cjsm2-l-sw / With lighting control and jack D51595 N/A $ 1,199.00 R-Net Attendant Module D50882 E2331 $ 799.00 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 $ 399.00 ISM 2L D50604 N/A $ 425.00 ISM 4 D50607 N/A $ 499.00 ISM 4L D50603 N/A $ 525.00 ISM 6 D50606 N/A $ 599.00 ISM 6L D50602 N/A $ 625.00 ISM 8 D51470 N/A $ 699.00 Expansion Modules R-Net Omni D50881 K0108 $ 1,499.00 Mounting hardware for R-Net Omni ASL 618 R- NET K0108 $ 599.00 Bluetooth Modules for Windows, Android and IDevices D51628 K0108 $ 350.00 Bluetooth 1 D5111 N/A $ 799.00 Bluetooth 2 D51523 N/A $ 799.00 Bluetooth IOS D51580 N/A $ 799.00 R-Net Accessories Battery - controller Connector D49712 K0108 $ 20.00 6 Actuator Module D50606 K0108 $ 599.00 R-Net 4-Connector Block D50829 K0108 $ 99.00 R-Net Cable 0.5 Meter, M-M SA77525L05 K0108 $ 129.00 R-Net Ext Cable 0.5 Meter, M-F SA78640L05 K0108 $ 129.00 Optional Items R-Net programming cable SA79174 N/A $ 79.00 R-Net Dongle (Dealer) D50610 N/A $ 499.00 R-Net PC Programmer (Dealer) D50612 N/A $ 299.00 4
Options Part HCPCS Number Code MSRP Accessories from Gel Ovations 3.5" X 12" Gel Armrests (Pair) 312G N/A $140 3.5" 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