Fillable F3 Corpus * Indicates a Required Field Dealer (USDA Food and Nutrition Service)

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F3 Corpus * Indicates a Required Field Dealer (USDA Food and Nutrition Service)

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Three column pricing on order/quote:
PO#:
_____________________________
_
Dealer Code
:_____________________________
_
*Dealer Name
:
_____________________________
_
* State/Zip:_____________________________
_
Order ID
:_____________________________
_
Address
:_____________________________
_
* Phone#:_____________________________
_
* 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:______________________________
_
Permobil Inc.
300 Duke Dr.
Lebanon, TN 37090
Tel: (800) 736-0925
Fax: (800) 231-3256
www.permobil.co
*City
:
_____________________________
_
Diagnosis:
_____________________________
_
Permobil recommends that the client is evaluated by a
certified rehab specialist.
Dealer Information
Client Information
Client Measurements
Funding Source:
_____________________________
_
Prices effective August 17, 2020
Client Age:
_____________________________
_
*ATP
:
_____________________________
_
* First Name:_____________________________
_
* Indicates a Required Field
* Last Name:_____________________________
_
Email Address:
_____________________________
_
Dis
p
la
y
HCPCS Codes on order/
q
uote:
Please send order/quote to fax#: (800) 231-3256
Email to: sales@permobil.com
F3 Corpus
F3 Corpus
Chair Model and Colors
CHOOSE BASE:
Part Numbe
r
Description Price HCPCS Code
I11331 F3 Base Corpus - F3 NPO 8,029.00 K0848
Price Includes: FWD F3 Power Base Set Up For No Power Seat Functions, ComfortRide Fully
Independent Adjustable Suspension, ESP (Enhanced Steering Performance), Tie-Down
Hardware for Strap Systems, Charger, Flat Free or Pneumatic Tires, a Standard Positioning
Belt and Permobil Connect. Max Speed = 6MPH, Weight Capacity = 300lbs, STFH = 17.5".
I11332 F3 Base Corpus - F3 SPO 8,029.00 K0856
Price Includes: FWD F3 Power Base Set Up For One Power Seat Function, ComfortRide Fully
Independent Adjustable Suspension, ESP (Enhanced Steering Performance), Tie-Down
Hardware for Strap Systems, Charger, Flat Free or Pneumatic Tires, a Standard Positioning
Belt and Permobil Connect. Max Speed = 6MPH, Weight Capacity = 300lbs, STFH = 17.5".
I108398-99-0 F3 Base Corpus - F3 MPO 8,029.00 K0861
Price Includes: FWD F3 Power Base Set Up For Multiple Power Seat Functions, ComfortRide
Fully Independent Adjustable Suspension, ESP (Enhanced Steering Performance), Tie-Down
Hardware for Strap Systems, Charger, Flat Free or Pneumatic Tires, a Standard Positioning
Belt and Permobil Connect. Max Speed = 6MPH, Weight Capacity = 300lbs, STFH = 17.5".
I11146 F3 Corpus to F5 Corpus Conversion Quote for Price
This option converts the Base to Group 4 (K0877 / K0884) and includes: 7.5 mph motor
p
ackage, ComfortRide Pro suspension and a 2-year warranty. The final price of the upgrade is
based on the items selected below. Please request a quote for pricing.
I11147 F3 Corpus to F5 Corpus VS Conversion Quote for Price
This option converts the Base to Group 4 (K0884) and Seat to Power Standing VS Seat
(E2301) and includes: 7.5 mph motor package, Comfort Ride Pro suspension, Power Support
Wheels and 2-year warranty. Unless otherwise specified, a 12"W Chest Support with Adj
Removable Hardware will be added to the upgrade order. Please request a quote for pricing.
SUPPORT WHEEL OPTIONS:
Part Numbe
r
Description Price HCPCS Code
I107330-99-0 Support Wheels for F3 No Charge
I11313 Omit Front Support Wheels No Charge
User Weight must not exceed 220lbs. Max speed will be limited to 5mph on the F3 Corpus and
6mph on the F5 Corpus. Additional restrictions may apply based on chair configuration.
CHOOSE DRIVE TIRES:
Part Numbe
r
Description Price HCPCS Code
I108414-99-0 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.
I108411-99-0 Pneumatic Tire 3"W x 14"T Black - Standard Tread No Charge
Includes flat free standard tread caster wheels.
I11333 Flat Free Tire 3"W x 14"T Black - Aggressive Tread 470.00
Includes flat free aggressive tread caster wheels and mud guards.
A
DDITIONAL WHEEL OPTIONS:
Part Numbe
r
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.
I11334 Mud Guard Kit - F3 40.00
CHOOSE SHROUD COLOR
:
Part Numbe
r
Description Price HCPCS Code
I108940-99-0 F3 Color Kit - Aqua No Charge
I108941-99-0 F3 Color Kit - Sky No Charge
I108942-99-0 F3 Color Kit - Violet No Charge
I108943-99-0 F3 Color Kit - Flamingo No Charge
I108944-99-0 F3 Color Kit - Chili No Charge
I108945-99-0 F3 Color Kit - Canary No Charge
I108946-99-0 F3 Color Kit - Spring No Charge
Pa
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Rev 2020-1 08/17/2020
F3 Corpus
Chair Model and Colors
CHOOSE SHROUD COLOR
:
Part Numbe
r
Description Price HCPCS Code
I108947-99-0 F3 Color Kit - Arctic No Charge
I108948-99-0 F3 Color Kit - Sunset No Charge
I108949-99-0 F3 Color Kit - Midnight No Charge
I108950-99-0 F3 Color Kit - Gold No Charge
I108951-99-0 F3 Color Kit - Bronze No Charge
I108952-99-0 F3 Color Kit - Platinum No Charge
I108953-99-0 F3 Color Kit - Carbon Fiber 204.00
I108954-99-0 F3 Color Kit - Mossy Oak Break-Up Country 204.00
I108955-99-0 F3 Color Kit - CDG Poly 204.00
I108957-99-0 F3 Color Kit - Fireball 204.00
I108958-99-0 F3 Color Kit - Water Lily 204.00
I108959-99-0 F3 Color Kit - Midnight Patriot 204.00
I108960-99-0 F3 Color Kit - American Liberty 204.00
CHOOSE HUB CAP KIT:
Part Numbe
r
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. __________________________________________________
I11343 Hydrographic Hub Cap Color: 50.00
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 EITHER SEAT ELEVATOR OR FIXED SEAT TUBE:
Part Numbe
r
Description Price HCPCS Code
I11110 Active Height Power Adj. Seat Height - 12" Travel 3,466.00 E2300
Must also select Power Tilt when selecting this option.
I11117 Seat Tube Fixed No Charge
SET SEAT HEIGHT:
Part Numbe
r
Description Price HCPCS Code
I107435-99-0 Set Seat Height to 17.5" No Charge
I107433-99-0 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".
I107434-99-0 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".
MUST CHOOSE BATTERIES:
Part Numbe
r
Description Price HCPCS Code
BATTERY OPTIONS:
I108999-99-0 Permobil Batteries, Grp 24 AGM GEL, Pair 1,002.00 E2363
For maximum range. Includes Permobil VoltPro charger optimized for Permobil Batteries.
I107032-99-0 Batteries, Grp 34 Gel, Pair 960.00 E2359
Includes Permobil Volt charger for non-Permobil gel batteries.
OPTIONAL ITEMS:
Part Numbe
r
Description Price HCPCS Code
I107459-99-0 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!
I108417-99-0 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!
I108418-99-0 LED Light Kit for F3 995.00
No charge with 4 power seat function configurations.
Pa
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Rev 2020-1 08/17/2020
F3 Corpus
Base Options
OPTIONAL ITEMS:
Part Numbe
r
Description Price HCPCS Code
I10715 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.
I10787 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.
I10788 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.
ID51113 Programming Key for R-net - Permobil Version 526.00
Joystick Options
CHOOSE JOYSTICK TYPE:
Part Numbe
r
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
j
ack; all in a compact, durable Aluminum housing.
I11186 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
p
rogrammable switch jack; all in a compact, durable Aluminum housing.
I107829-99-0 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.
I105246-99-0 R-net LED Remote Joystick - No Display No Charge
This Joystick does NOT have a Display Screen, does NOT contain mono jack ports, and does
NOT include Bluetooth or Assignable Buttons. PC Programming required and profiles limited t
o
five.
I105700-99-0 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 Numbe
r
Description Price HCPCS Code
I10045 Cone Shaped Joystick Knob - Standard No Charge
I100960-99-0 Chin Cup For Joystick Knob 127.00 E2324
I100961-99-0 "T" Handle For Joystick Knob 179.00 E2323
I100962-99-0 "Large Ball" For Joystick Knob 127.00 E2323
I100963-99-0 "Softball" For Joystick Knob 167.00 E2323
I100964-99-0 "Mushroom" For Joystick Knob 167.00 E2323
I100965-99-0 "Stick" For Joystick Knob 167.00 E2323
I105442-99-0 1.75" Black Foam Ball For Joystick Knob 127.00 E2323
I105846-99-0 Bodypoint J/S Handle 3" U-Shaped w/ Flex-Shaft 167.00 E2323
I105847-99-0 Bodypoint J/S Handle 4" U-Shaped w/ Flex-Shaft 167.00 E2323
I105848-99-0 Bodypoint J/S Handle Dome Shaped, Rubber 167.00 E2323
CHOOSE JOYSTICK MOUNT:
Part Numbe
r
Description Price HCPCS Code
I10664 Joystick Mount Right - Fixed No Charge
I10665 Joystick Mount Left - Fixed No Charge
Page 4 of 19
Rev 2020-1 08/17/2020
F3 Corpus
Joystick Options
CHOOSE JOYSTICK MOUNT:
Part Numbe
r
Description Price HCPCS Code
I102537-99-0 Joystick Mount Right - Swing Away 374.00 E1028
I102538-99-0 Joystick Mount Left - Swing Away 374.00 E1028
I108037-99-0 Slimline Retractable Joystick Mount - Right 503.00 E1028
I108038-99-0 Slimline Retractable Joystick Mount - Left 503.00 E1028
I11232 Adjustable Height Panel Bracket 273.00 E1028
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.
I105210-99-0 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: _____
I108268-99-0 Bodypoint Tri-Lock Midline Mount Assembly 642.00
Includes L-shaped joystick arm and height adjustable mounting clamp. Joystick mount sold
separately (select from the mounts listed below). Please indicate if you want midline mounted
on left or right armrest:
Mount Midline on Left Armrest: _____ Mount Midline on Right Armrest: _____
I108280-99-0 Bodypoint Tri-Lock Mount for R-net JS 267.00
I108279-99-0 Bodypoint Tri-Lock Mount for Compact Joystick 267.00
I10842 PERMOFix Mount for Mini/Compact Joystick 267.00
Includes a shim washer that allows the PERMOFix joint to be mounted on the joystick arm.
Provides an adjustable mount for a Mini Joystick or Compact Joystick.
OPTIONAL ITEMS:
Part Numbe
r
Description Price HCPCS Code
I10411 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.
I10513 Harness for Expandable Controller 620.00 E2313
Must be ordered with any Expandable Controller.
I105225-99-0 Co-Pilot Attendant Control R-net - Corpus 5,115.00 E2331
I105408-99-0 Attendant Control R-net 1,372.00 E2331
I107350-99-0 R-net Bluetooth iDevice Module 962.00 K0108
A
llows 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.
I107367-99-0 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.
I107368-99-0 Add a second Bluetooth Mouse Module 962.00 K0108
A
llows 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.
I10582 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.
Seating System
CHOOSE POSTERIOR TILT/RECLINE PACKAGE:
Part Numbe
r
Description Price HCPCS Code
Page 5 of 19
Rev 2020-1 08/17/2020
F3 Corpus
Seating System
CHOOSE POSTERIOR TILT/RECLINE PACKAGE:
Part Numbe
r
Description Price HCPCS Code
PLEASE NOTE:
A
half speed limitation is imposed when the Total Backrest Angle (TBA) > 150°. TBA = Tilt
A
ngle + Backrest Recline Angle. Example 1: 45° Tilt + 100° Recline = 145° TBA (Full Speed).
Example 2: 35° Tilt + 120° Recline = 155° TBA (Half Speed).
I11130 Corpus Seat w/ No Tilt 7,807.00
Backrest angle can be manually adjusted up to 120°
I11131 Corpus Seat w/ No Tilt & 180° Power Recline 8,750.00 E1004
I11132 Corpus Seat w/ 50° Tilt 7,807.00 E1002
Backrest angle can be manually adjusted up to 120°
I11133 Corpus Seat w/ 50° Tilt & 180° Power Recline 12,355.00 E1007
A
CTIVE REACH PACKAGES:
Part Numbe
r
Description Price HCPCS Code
PLEASE NOTE:
A
ctiveReach should be recommended by a licensed clinical professional and/or ATP. While
operating ActiveReach, positioning equipment such as lap belts and chest supports should be
considered to meet the user's specific safety needs. Note: A low speed limitation is imposed
from 5° of ActiveReach and Drive inhibit will occur at 10° or greater.
I11141 5° Active Reach No Charge
When ordered with a Power Adjustable Seat Height, tilt range will be -5° to +50°. When
ordered without a Power Adjustable Seat Height, tilt range will be -5° to +45°. If this option is
selected with a fixed seat, the minimum seat to floor height at 0° of tilt will be approximately
19.5". Power Legrest recommended for full functionality. Minimum legrest angle will be ~ 97°
when manual legrest is selected.
I107090-99-0 10° Active Reach No Charge
Please Note: This option is only available on configurations ordered with Power Adjustable
Seat Height and Power Tilt. A chest support belt (see Accessories section) is strongly
recommended when selecting this option. Power Legrest recommended for full functionality.
Minimum legrest angle will be ~ 103° when manual legrest is selected.
I107091-99-0 20° Active Reach 2,716.00 K0108
Please Note: This option is only available on configurations ordered with Power Adjustable
Seat Height, Power Tilt, Power Recline and Power Legrest Elevation. Must select Corpus VS
Power Elevating Legrest, Corpus VS Footplates and Corpus VS Knee Support from VS
Legrest Options section. A chest support belt (see Accessories section) is strongly
recommended when selecting this option. Not compatible with retractable positioning belts.
I11100 30° Active Reach w/Transfer 3,054.00 K0108
Please Note: This option is only available on configurations ordered with Power Adjustable
Seat Height, Power Tilt, Power Recline and Power Legrest Elevation. Must select Corpus VS
Power Elevating Legrest, Corpus VS Footplates and Corpus VS Knee Support from VS
Legrest Options section. A chest support belt (see Accessories section) is strongly
recommended when selecting this option. Not compatible with retractable positioning belts.
Seating System Options
CHOOSE SEAT FUNCTION CONTROL TYPE:
Part Numbe
r
Description Price HCPCS Code
I10418 Seat Function Control Switch for R-net No Charge
Please choose either Push Buttons or Toggle Switches below. Does not include thru drive
control operation of power seat functions.
I10419 Single Seat Function Control Kit for R-net 1,932.00 E2310
For operation of a single seat function 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.
I10585 Multiple Seat Function Control Kit for R-net 3,657.00 E2311
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.
CHOOSE PUSH BUTTONS OR TOGGLES:
Part Numbe
r
Description Price HCPCS Code
I102798-99-0 Push Buttons on ICS Switchbox (1.4m) No Charge
Page 6 of 19
Rev 2020-1 08/17/2020
F3 Corpus
Seating System Options
CHOOSE PUSH BUTTONS OR TOGGLES:
Part Numbe
r
Description Price HCPCS Code
I102799-99-0 Toggle Switches on ICS Switchbox (1.4m) 327.00
I105409-99-0 Do Not Install ICS Switchbox, Send as Part No Charge
CHOOSE MOUNTING POSITION OF ICS SWITCHBOX:
Part Numbe
r
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
is selected, the ICS Switchbox will swing away with the Joystick Module.
I104651-99-0 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 Numbe
r
Description Price HCPCS Code
I104196-99-0 ICS Alternative Switchbox for R-net Electronics 1,278.00 K0108
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.
I108416-99-0 Remote Stop System 1,264.00 E2321
Consists of a 315MHz Radio Frequency (RF) handheld transmitter and an RF receiver
mounted on the wheelchair.
I10750 Memory Seat Program, Corpus w/ R-net 132.00
I106209-99-0 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.
I10898 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 Numbe
r
Description Price HCPCS Code
I105067-99-0 Sliding Backrest Kit - 5" Mechanical Shear No Charge
I105066-99-0 Fixed Backrest Kit - No Mechanical Shear 39.00
CORPUS BACKREST OPTIONS:
Part Numbe
r
Description Price HCPCS Code
BACKREST HEIGHT NOTE:
Backrest heights are measured from the seat pan to the top of the backrest shell with the
backrest set at 90°. Corpus Ergo Backs include lateral wedges and foam lumbar pads. Solid
Backs do not include foam lumbar pads.
I106545-99-0 Corpus Ergo Back - 14"W x 20"T (C3GERGBCA) 1,091.00 E2620
Power Recline will be limited to 150° when ordering this backrest.
I106546-99-0 Corpus Ergo Back - 16"W x 20"T (C3GERGBCA) 1,091.00 E2620
Power Recline will be limited to 150° when ordering this backrest.
I106547-99-0 Corpus Ergo Back - 18"W x 20"T (C3GERGBCA) 1,091.00 E2620
Power Recline will be limited to 150° when ordering this backrest.
I106548-99-0 Corpus Ergo Back - 20"W x 20"T (C3GERGBCA) 1,091.00 E2620
Power Recline will be limited to 150° when ordering this backrest.
I11104 Solid Corpus Ergo Back - 16"W x 20"T No Charge
Power Recline will be limited to 150° when ordering this backrest.
I11105 Solid Corpus Ergo Back - 18"W x 20"T No Charge
Power Recline will be limited to 150° when ordering this backrest.
Page 7 of 19
Rev 2020-1 08/17/2020
F3 Corpus
Backrest Options
CORPUS BACKREST OPTIONS:
Part Numbe
r
Description Price HCPCS Code
I11106 Solid Corpus Ergo Back - 20"W x 20"T No Charge
Power Recline will be limited to 150° when ordering this backrest.
PLEASE NOTE:
Taller backrests listed below 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 below where you want the height set at so that a properly
sized backrest cushion can be provided. * Foam lumbar pads not included with Solid Backs.
I106532-99-0 Corpus Ergo Back - 14"W x 23" - 28"T (C3GERGBCA) 1,095.00 E2620
I106533-99-0 Corpus Ergo Back - 16"W x 23" - 28"T (C3GERGBCA) 1,095.00 E2620
I106534-99-0 Corpus Ergo Back - 18"W x 23" - 28"T (C3GERGBCA) 1,095.00 E2620
I106535-99-0 Corpus Ergo Back - 20"W x 23" - 28"T (C3GERGBCA) 1,095.00 E2620
I11107 Solid Corpus Ergo Back - 16"W x 23" - 28"T No Charge
I11108 Solid Corpus Ergo Back - 18"W x 23" - 28"T No Charge
I11109 Solid Corpus Ergo Back - 20"W x 23" - 28"T No Charge
.
MUST ALSO SELECT BACK HEIGHT:
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 Numbe
r
Description Price HCPCS Code
I11335 Leatherette Cushion - Corpus Ergo Back No Charge
Includes Dual Density Backrest Foam.
I11336 Stretch-Air Cushion - Corpus Ergo Back No Charge
Includes Dual Density Backrest Foam with Stretch-Air breathable fabric cover.
I11339 Foam Lumbar Pads for Solid Back - Corpus 40.00
A
GILITY BACKREST OPTIONS:
Part Numbe
r
Description Price HCPCS Code
ROHO AGILITY NOTE:
The ROHO AGILITY Back Systems are available in widths of 14", 16", 18" and 20" and shell
heights of 16", 18" and 20". Includes backrest shell, cushion, air inserts, UT rail for headrest
and Direct Mount adapter. If ordered with a headrest, extended headrest receiver will be
p
rovided for backrests heights less than 25".
I11258 ROHO AGILITY Max Contour Direct Mount - 16" Tall 779.00 E2620
Backrest can be installed at a height (seat pan to top of AGILITY) between 22" and 25".
Specify Shell Width (14", 16", 18", 20"W):______
I11259 ROHO AGILITY Max Contour Direct Mount - 18" Tall 779.00 E2620
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):______
I11260 ROHO AGILITY Max Contour Direct Mount - 20" Tall 779.00 E2620
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):______
MUST ALSO SELECT BACK HEIGHT:
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" _____
Page 8 of 19
Rev 2020-1 08/17/2020
F3 Corpus
Backrest Options
CHOOSE ONE OF THE FOLLOWING:
Part Numbe
r
Description Price HCPCS Code
I109029-99-0 BodiLink Premium 3" x 5" Lateral Supports - Pair 425.00 E0956
Must also select I109031-99-0. Includes foam wedge for additional support. Only compatible
with Corpus Ergo backrest shells.
I109030-99-0 BodiLink Premium 4" x 6" Lateral Supports - Pair 425.00 E0956
Must also select I109031-99-0. Includes foam wedge for additional support. Only compatible
with Corpus Ergo backrest shells.
I109031-99-0 Swing-Away Adj BodiLink Lateral Hdwr Corpus Pair 595.00 E1028
OPTIONAL ITEMS:
Part Numbe
r
Description Price HCPCS Code
I105782-99-0 Tubular Backrest Frame - Corpus (1" Canes) 510.00
Provides 1" diameter, vertical canes for mounting aftermarket backrests. Frame can be
adjusted to support backrest widths from 14" to 20". Canes are attached with 2" long UniTrack
linkage disks that can rotate to provide space for backrest hardware. The tops of the canes
can be adjusted up to a height of 27" above the seat pan. Depending on the aftermarket
backrest, several inches of seat depth may be lost when mounting this system.
I106072-99-0 Direct Backrest Frame - Corpus 510.00 K0108
Used to mount ROHO Agility, Jay 3, Matrx Elite, Varilite Icon and Ride Java backrests ranging
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.
I10725 Split Backrest Cushion - Corpus 345.00 E2617
Custom Option.
I10786 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 Numbe
r
Description Price HCPCS Code
I107023-99-0 Set Seat Width at 17": ____ No Charge
I107024-99-0 Set Seat Width at 19": ____ No Charge
I107025-99-0 Set Seat Width at 21": ____ No Charge
I107026-99-0 Set Seat Width at 23": ____ No Charge
CHOOSE SEAT DEPTH:
Part Numbe
r
Description Price HCPCS Code
PLEASE NOTE:
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.
I107013-99-0 Seat Depth 14" No Charge
I107014-99-0 Seat Depth 15" No Charge
I107015-99-0 Seat Depth 16" No Charge
I107016-99-0 Seat Depth 17" No Charge
I107017-99-0 Seat Depth 18" No Charge
I107018-99-0 Seat Depth 19" No Charge
I107019-99-0 Seat Depth 20" No Charge
I107020-99-0 Seat Depth 21" No Charge
I107021-99-0 Seat Depth 22" No Charge
CHOOSE SEAT CUSHION:
Part Numbe
r
Description Price HCPCS Code
NOTE:
A
Corpus II Ergonomic Seat Cushion will be provided for select seat sizes.
I11337 Corpus Ergo Cushion - Leatherette Cover 578.00 E2605
I11338 Corpus Ergo Cushion - Stretch-Air Cover 578.00 E2605
Page 9 of 19
Rev 2020-1 08/17/2020
F3 Corpus
Seat Sizing
CHOOSE SEAT CUSHION:
Part Numbe
r
Description Price HCPCS Code
I10965 Corpus Ergo Air Cushion (C3GRHOSCA) 611.00 E2622
Features ROHO Dry Floatation technology. The removable ROHO cell pad provides adjustabl
e
skin protection while the contoured foam and thigh support wedges help maintain proper
p
ositioning 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"
I11113 Incontinence Cover for Ergo Cushion 186.00 E2619
Made from a stretch Dartex fabric and suitable for all Ergo cushions including the Corpus Ergo
A
ir. 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.
I11166 ROHO QUADTRO SELECT HIGH PROFILE < 22"W 586.00 E2624
Registered in PDAC under ROHO model numbers QS98C - QS1114C.
I11167 ROHO QUADTRO SELECT HIGH PROFILE > or = 22"W 628.00 E2625
Registered in PDAC under ROHO model numbers QS128C - QS1413C.
I11168 ROHO HIGH PROFILE Single Comp < 22"W 586.00 E2622
Registered in PDAC under ROHO model numbers 1R98C - 1R1114C.
I11169 ROHO HIGH PROFILE Single Comp > or = 22"W 628.00 E2623
Registered in PDAC under ROHO model numbers 1R138C - 1R1414C.
I11170 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.
I11171 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.
I107505-99-0 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.
I11173 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.
I105118-99-0 Omit Seat Cushion No Charge
Armrest Options
CHOOSE ARMBAR KIT AND MOUNTING POSITION:
Part Numbe
r
Description Price HCPCS Code
PLEASE NOTE:
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
p
ads without any additional parts. Please select both Armbar Kit and Width Setting below.
I106543-99-0 Narrow Armbar Kit, Inf Adjustable 15"W - 19"W No Charge
I106544-99-0 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 Numbe
r
Description Price HCPCS Code
I105069-99-0 Height Adjustable Armrests - NC No Charge
No charge when ordering power tilt and/or recline.
I105081-99-0 Height Adjustable Armrests 358.00
Must be selected when the NPO base is selected.
SET ARMREST HEIGHT AT:____
Corpus Armrests are infinitely adjustable from 8" - 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: 8", 9", etc.), please indicate where you would like the armrests set.
CHOOSE ARMREST SWIVEL FIXED OR ENABLED:
Page 10 of 19
Rev 2020-1 08/17/2020
F3 Corpus
Armrest Options
CHOOSE ARMREST SWIVEL FIXED OR ENABLED:
Part Numbe
r
Description Price HCPCS Code
I105071-99-0 Left Armrest Bracket - Fixed No Charge
Medial swivel cannot be enabled when selecting this option. Must be selected when ordering
arm trough adapters.
I105070-99-0 Right Armrest Bracket - Fixed No Charge
Medial swivel cannot be enabled when selecting this option. Must be selected when ordering
arm trough adapters.
I105073-99-0 Left Armrest Bracket - Medial Swivel Enabled No Charge
I105072-99-0 Right Armrest Bracket - Medial Swivel Enabled No Charge
CHOOSE ARMREST PAD RIGHT:
Part Numbe
r
Description Price HCPCS Code
I105100-99-0 4"x10" Corpus Armrest Pad Right - Leatherette No Charge
I105104-99-0 4"x13" Corpus Armrest Pad Right - Leatherette No Charge
I105105-99-0 4"x16" Corpus Armrest Pad Right - Leatherette No Charge
I105999-99-0 4"x18" Corpus HD Armrest Pad Right - Leatherette No Charge
I107212-99-0 4"x10" Corpus Armrest Pad Right - Black Fabric No Charge
I106047-99-0 4"x13" Corpus Armrest Pad Right - Black Fabric No Charge
I107214-99-0 4"x16" Corpus Armrest Pad Right - Black Fabric No Charge
I105995-99-0 4"x18" Corpus HD Armrest Pad Right - Black Fabric No Charge
I107591-99-0 4"x10" Corpus Arm w/ Permobil Gel Pad - Right 175.00
I107593-99-0 4"x13" Corpus Arm w/ Permobil Gel Pad - Right 180.00
I107595-99-0 4"x16" Corpus Arm w/ Permobil Gel Pad - Right 185.00
I107597-99-0 4"x18" Corpus HD Arm w/ Permobil Gel Pad - Right 190.00
I108861-99-0 Moldable Forearm Support - Right 258.00
11.3"L x 5"W. Not compatible with armrest pouch, trays (except Small Tray) or the VS Chest
Support.
I108863-99-0 Contoured Hand Pad Medium - Right 128.00
6.4"L x 5.5" W. For use with Moldable Forearm Supports only. Not compatible with Slimline or
Fixed joystick mounts or Adjustable Height Panel Bracket.
I108865-99-0 Contoured Hand Pad Large - Right 135.00
7.7"L x 6.1" W. For use with Moldable Forearm Supports only. Not compatible with Slimline or
Fixed joystick mounts or Adjustable Height Panel Bracket.
CHOOSE ARMREST PAD LEFT:
Part Numbe
r
Description Price HCPCS Code
I105098-99-0 4"x10" Corpus Armrest Pad Left - Leatherette No Charge
I105102-99-0 4"x13" Corpus Armrest Pad Left - Leatherette No Charge
I105107-99-0 4"x16" Corpus Armrest Pad Left - Leatherette No Charge
I105998-99-0 4"x18" Corpus HD Armrest Pad Left - Leatherette No Charge
I107213-99-0 4"x10" Corpus Armrest Pad Left - Black Fabric No Charge
I106046-99-0 4"x13" Corpus Armrest Pad Left - Black Fabric No Charge
I107215-99-0 4"x16" Corpus Armrest Pad Left - Black Fabric No Charge
I105994-99-0 4"x18" Corpus HD Armrest Pad Left - Black Fabric No Charge
I107590-99-0 4"x10" Corpus Arm w/ Permobil Gel Pad - Left 175.00
I107592-99-0 4"x13" Corpus Arm w/ Permobil Gel Pad - Left 180.00
I107594-99-0 4"x16" Corpus Arm w/ Permobil Gel Pad - Left 185.00
I107596-99-0 4"x18" Corpus HD Arm w/ Permobil Gel Pad - Left 190.00
I108860-99-0 Moldable Forearm Support - Left 258.00
11.3"L x 5"W. Not compatible with armrest pouch, trays (except Small Tray) or the VS Chest
Support.
I108862-99-0 Contoured Hand Pad Medium - Left 128.00
6.4"L x 5.5" W. For use with Moldable Forearm Supports only. Not compatible with Slimline or
Fixed joystick mounts or Adjustable Height Panel Bracket.
Page 11 of 19
Rev 2020-1 08/17/2020
F3 Corpus
Armrest Options
CHOOSE ARMREST PAD LEFT:
Part Numbe
r
Description Price HCPCS Code
I108864-99-0 Contoured Hand Pad Large - Left 135.00
7.7"L x 6.1" W. For use with Moldable Forearm Supports only. Not compatible with Slimline or
Fixed joystick mounts or Adjustable Height Panel Bracket.
OPTIONAL ITEMS:
Part Numbe
r
Description Price HCPCS Code
I105463-99-0 Corpus Arm Trough Adapter 1" - Pair 345.00
For aftermarket armrest pads. Please indicate below if they should be installed or on chair
sent as parts. Please Note: Medial Swivel must be must be locked (I10645 & I10646) when
selecting this option.
I105462-99-0 Corpus Arm Trough Adapter 7/8" - Pair 345.00
For aftermarket armrest pads. Please indicate below if they should be installed or on chair
sent as parts. Please Note: Medial Swivel must be must be locked (I10645 & I10646) when
selecting this option.
Install Arm Trough Adapters: _____
Send Arm Trough Adapters as Parts: _____
I107339-99-0 Armrest Pouch - Right 244.00
I107338-99-0 Armrest Pouch - Left 244.00
I107840-99-0 UT Armrest Side Support - Right Outer 352.00
Includes 2"T x 6.5"W tapered pad.
I107863-99-0 UT Armrest Side Support - Left Outer 352.00
Includes 2"T x 6.5"W tapered pad.
I107864-99-0 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.
I107865-99-0 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.
I107839-99-0 UT Elbow Support - Right 174.00 K0108
Must also select PN I10881.
I107838-99-0 UT Elbow Support - Left 174.00 K0108
Must also select PN I10882.
I10881 Adjustable Elbow Support Hardware - Right 256.00
I10882 Adjustable Elbow Support Hardware - Left 256.00
Legrest Options
CORPUS LEGREST OPTIONS:
Part Numbe
r
Description Price HCPCS Code
CHOOSE LEGREST TYPE:
I107763-99-0 Corpus Manual Elevating Legrest No Charge
I107757-99-0 Corpus Power Elevating Legrest - 170° 3,756.00 E1012
Includes mechanical articulation.
CHOOSE FOOTPLATE STYLE:
I105437-99-0 2pc Wide Corpus Footplates - 9"D x 7.5"W No Charge
I105436-99-0 2pc Narrow Corpus Footplates - 9"D x 6"W 269.00
I106760-99-0 1pc Narrow Corpus Footpl - 9.75"D x 12.5"W 269.00
Footplate is 12.5"W in front, 8"W in back.
CALF SUPPORT OPTIONS:
I105252-99-0 UT Calf Support Kit (B) w Mesh Cover & Adj Hardware No Charge
3.5"W x 4.5"T Pad.
I105258-99-0 UT Calf Support Kit (J) w Mesh Cover & Adj Hardware No Charge
5"W x 6.5"T Pad.
I105250-99-0 UT Calf Support Kit (A) w Mesh Cover & Adj Hardware No Charge
5.5"W x 6"T Pad.
Page 12 of 19
Rev 2020-1 08/17/2020
F3 Corpus
Legrest Options
CORPUS LEGREST OPTIONS:
Part Numbe
r
Description Price HCPCS Code
I105256-99-0 UT Calf Support Kit (H) w Mesh Cover & Adj Hardware 384.00
7"W x 7"T Curved Pad.
I105254-99-0 UT Calf Support Kit (D) w Mesh Cover & Adj Hardware 384.00
8"W x 8"T Pad.
CORPUS VS LEGREST OPTIONS (FOR SELECT ACTIVE REACH PACKAGES):
Part Numbe
r
Description Price HCPCS Code
CORPUS VS LEGREST AND KNEE SUPPORT:
NOTE: The Corpus VS Legrest is only available with 20°, 30° and 45° of Active Reach.
I107758-99-0 Corpus VS Power Elevating Legrest - 180° 3,756.00 E1012,K0108
Includes power articulation.
I107038-99-0 Knee Support/Abductor - Corpus VS 267.00 E0957
Select when ordering Corpus VS Legrest. Must also select I11129.
I11129 Adj Removable Knee Support Hardware (1 Each) 280.00
.
CHOOSE FOOTPLATE STYLE:
I106969-99-0 1pc Corpus VS Footplate - 9"D x 16.5"W No Charge
I106971-99-0 2pc Wide Corpus VS Footplates - 9"D x 7.5"W 289.00
I106967-99-0 2pc Narrow Corpus VS Footplates - 9"D x 6"W 289.00 K0108
.
CALF SUPPORT OPTIONS:
I107211-99-0 VS Calf Support Kit (J) w Mesh Cover & Adj Hardware No Charge
5"W x 6.5"T Pad. Compatible with footplate heights of 10" - 18".
I106190-99-0 VS Calf Support Kit (A) w Mesh Cover & Adj Hardware No Charge
5.5"W x 6"T Pad. Compatible with footplate heights of 10" - 18".
I106188-99-0 VS Calf Support Kit (H) w Mesh Cover & Adj Hardware 378.00
7"W x 7"T Curved Pad. Compatible with footplate heights of 11" - 18".
I106186-99-0 VS Calf Support Kit (D) w Mesh Cover & Adj Hardware 378.00
8"W x 8"T Pad. Compatible with footplate heights of 12" - 18".
FOOTPLATE HEIGHT POSITION:
Part Numbe
r
Description Price HCPCS Code
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 Numbe
r
Description Price HCPCS Code
I106530-99-0 Stealth Gel Pads - Narrow Footplates (Pair) 430.00
I106225-99-0 Stealth Gel Pads - Wide Footplates (Pair) 440.00
Accessories
I104518-99-0 Bodypoint Non-Padded Hip Belt - Medium No Charge
I104520-99-0 Bodypoint Padded Hip Belt - Medium 153.00
I104514-99-0 Bodypoint Non-Padded Hip Belt - Large 130.00
I104516-99-0 Bodypoint Padded Hip Belt - Large 204.00
I100519-99-0 Positioning Belt Retractable 304.00
I100600-99-0 Positioning Belt Retractable Long 315.00
I108267-99-0 Bodypoint Padded Hip Belt "Airplane" Latch - Med 205.00
I108266-99-0 Bodypoint Padded Hip Belt "Airplane" Latch - Large 215.00
HEADREST OPTIONS:
Part Numbe
r
Description Price HCPCS Code
Page 13 of 19
Rev 2020-1 08/17/2020
F3 Corpus
Accessories
HEADREST OPTIONS:
Part Numbe
r
Description Price HCPCS Code
I107470-99-0 Permobil 7"W Headrest w/ Link Hardware 397.00 E0955
Must also select I107480-99-0 or I107481-99-0.
I107469-99-0 Permobil 10"W Headrest w/ Link Hardware 397.00 E0955
Must also select I107480-99-0 or I107481-99-0.
I107468-99-0 Permobil 14"W Headrest w/ Link Hardware 397.00 E0955
Must also select I107480-99-0 or I107481-99-0.
I107480-99-0 Adj/Removable Headrest Link Hardware - Standard 273.00 E1028
I108721-99-0 Adj/Removable BodiLink Head Support Hdwr - MAX 8 330.00 E1028
Must be selected when ordering more than 2 swing-away headrest accessories or chin boom
assemblies.
I11305 Swing Away Egg Switch Assembly 586.00 E1028
Mount on Upper Left:____ Mount on Upper Right:_____
I11306 Swing Away Microlight Assembly 668.00 E1028
Mount on Upper Left:____ Mount on Upper Right:_____
I11307 Swing Away Facial Pad Assembly 4"L x 2"T 475.00 E1028
Mount on Upper Left:____ Mount on Upper Right:_____
I11308 Swing Away Facial Pad Assembly 6"L x 2"T 475.00 E1028
Mount on Upper Left:____ Mount on Upper Right:_____
I11276 Provide Headrest Receiver for AGILITY Backrest No Charge
Select for AGILITY backs and third party backs ordered off chair.
I106331-99-0 Permobil 10"W Headrest, Leatherette 363.00 E0955
Not available with ROHO AGILITY Back Systems. Must also select PN I10552.
I10552 Adj/Removable Headrest Hardware 280.00 E1028
I107499-99-0 Universal Headrest Adapter 276.00
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 Numbe
r
Description Price HCPCS Code
I103070-99-0 UT Amp. Support Pad (H) w/ Mesh Cover - (1 Each) 165.00 E1020
7"W x 7"T Curved Pad. Must also select PN I10553.
I103071-99-0 UT Amp. Support Pad (D) w/ Mesh Cover - (1 Each) 165.00 E1020
8"W x 8"T Flat Pad. Must also select PN I10553.
I10553 Adj Removable - Amp Support Hardware (1 Each) 280.00
Please indicate if you would like the amputation support mounted on the right or left side of the
seat frame:
Mount Amp Suppt on Left: ____ Mount Amp Suppt on Right: ____
I109040-99-0 BodiLink Premium LPTS Pad (B), Stretch-Air - Pair 325.00 E0953
4.5"W x 3.5"T Pad w/additional foam insert and Stretch-Air cover. Must also select BodiLink
LPTS Mounting Hardware.
I109043-99-0 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
LPTS Mounting Hardware.
I109041-99-0 BodiLink Premium LPTS Pad (C), Stretch-Air - Pair 325.00 E0953
8"W x 3.5"T Pad w/additional foam insert and Stretch-Air cover. Must also select BodiLink
LPTS Mounting Hardware.
I109042-99-0 BodiLink Premium LPTS Pad (G), Stretch-Air - Pair 325.00 E0953
12"W x 3.5"T Pad w/additional foam insert and Stretch-Air cover. Must also select BodiLink
LPTS Mounting Hardware.
I109044-99-0 Adj/Removable BodiLink LTPS Hdwr Med Corpus Pair 625.00 E1028
Medium TT Power Mount hardware can be extended upward to clear cushions of 3-5.5" thick.
I109194-99-0 Adj/Removable Lateral Thigh/Hip Hardware - Pair 551.00 E1028
I106762-99-0 Abductor Kit Corpus - Leatherette 387.00 E0957
Must also select PN I10555.
I10555 Adj Removable - Abductor Hardware (1 Each) 280.00 E1028
Page 14 of 19
Rev 2020-1 08/17/2020
F3 Corpus
Accessories
OPTIONAL ITEMS:
Part Numbe
r
Description Price HCPCS Code
I105260-99-0 Transfer Handles, Corpus Seat 503.00 K0108
I105292-99-0 Push Handles, Corpus Seat 447.00
I106210-99-0 RAM Self-Leveling Cup Holder 85.00
I106806-99-0 RAM X-Grip Phone Holder 85.00
I107100-99-0 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.
I107222-99-0 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: _____
I105805-99-0 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.
I102059-99-0 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.
I105840-99-0 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.
I105839-99-0 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.
I105850-99-0 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.
I105262-99-0 Joystick Cutout Tray - 16" W 401.00 E0950
Must also select PN I10556.
I105263-99-0 Joystick Cutout Tray - 18" W 401.00 E0950
Must also select PN I10556.
I10843 Small Angle Adjustable Tray 309.00 E0950
Must also select PN I10556.
Mount on Left: _____ Mount on Right: _____
I10556 Adj Removable - Tray Hardware (1 Each) 280.00
I108230-99-0 Permobil Adjustable Tray - 13"W 260.00 E0950
I108228-99-0 Permobil Adjustable Tray - 15"W 260.00 E0950
I108227-99-0 Permobil Adjustable Tray - 17"W 260.00 E0950
I108229-99-0 Permobil Adjustable Tray - 19"W 260.00 E0950
I108232-99-0 Permobil Tray Hardware Right Side Adjustable 190.00
I108233-99-0 Permobil Tray Hardware Left Side Adjustable 190.00
I105224-99-0 Oxygen Holder, Corpus 275.00
I105223-99-0 Crutch Holder, Corpus 275.00 E2207
Alternative Drive Systems
A
LTERNATIVE PROPORTIONAL JOYSTICK SYSTEMS:
Part Numbe
r
Description Price HCPCS Code
I10751 Mini-Joystick for Omni - (9-pin connector) 3,314.00 E2312
Operating Force = 0.5 oz (13 g) Neutral to Full Deflection = 0.2" (5mm)
I103893-99-0 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)
Foam Ball Knob.
Page 15 of 19
Rev 2020-1 08/17/2020
F3 Corpus
Alternative Drive Systems
A
LTERNATIVE PROPORTIONAL JOYSTICK SYSTEMS:
Part Numbe
r
Description Price HCPCS Code
I103894-99-0 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.
A
LT PROPORTIONAL JOYSTICK MOUNTING HARDWARE:
Part Numbe
r
Description Price HCPCS Code
NOTE:
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.
I107946-99-0 Swing Away Chin Boom Assm for Compact Lite - Left 425.00 E1028
I107948-99-0 Swing Away Chin Boom Assm for Compact Lite - Right 425.00 E1028
I107857-99-0 Swing Away Chin Boom Assm for Mini Joystick - Left 425.00 E1028
I107947-99-0 Swing Away Chin Boom Assm for Mini Joystick - Right 425.00 E1028
I104690-99-0 Alt JS Swing Away Mount Kit - Armrest 284.00 E1028
Mount in front of Left Arm: _____ Mount in front of Right Arm: _____
I107135-99-0 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.
Mount in front of Left Arm: _____ Mount in front of Right Arm:_____
I104143-99-0 Alt JS Adjustable Mount Kit - Chin Boom 885.00 E1028
Swing-Away / Removable Chin Boom mounted on right of backrest shell. Custom charge may
be applied if ordering lower backrest heights.
I10752 Haims Harness for Chin Control Mount, Large 629.00 E1028
For neck width up to 7½".
I10753 Haims Harness for Chin Control Mount, Small 629.00 E1028
For neck width up to 5½".
A
LT PROPORTIONAL JOYSTICK ACCESSORIES:
Part Numbe
r
Description Price HCPCS Code
I104904-99-0 Dual Switches for Compact Joystick - Fixed Mount 263.00
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: _____
I104641-99-0 Dual Switches for Compact Joystick -Gooseneck Mount 474.00
Includes two pushbutton switches mounted on adjustable gooseneck arms. Switches are
p
ositioned 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 Numbe
r
Description Price HCPCS Code
I10573 Sip & Puff System for Omni 1,773.00 E2325,E2326
Requires Omni Control Module. Includes breath tube kit.
I10574 Sip & Puff System with Fiber Optic Opti-Stop 2,360.00 E2325,E2326
Requires Omni Control Module. Includes breath tube kit.
I106807-99-0 Sip & Puff Kit for Total Control Head Array 914.00 E2325
For use with Total Control Head Array. Requires Omni Control Module. Includes breath tube
kit.
I10762 Adjustable Mounting Hrdw - Sip & Puff 284.00
Required when selecting PN I10573, I10574 or I106807-99-0.
PROPORTIONAL FOOT CONTROL:
Part Numbe
r
Description Price HCPCS Code
I10767 Proportional Foot Control 3,379.00
Not available with Active Reach Packages.
Mount on Left: _____ Mount on Right: _____
Page 16 of 19
Rev 2020-1 08/17/2020
F3 Corpus
Alternative Drive Systems
PROPORTIONAL FOOT CONTROL:
Part Numbe
r
Description Price HCPCS Code
I10766 Adjustable Mounting Hrdw - Foot Control 284.00
Required when selecting PN I10767.
Total Control Head Array
CONFIGURE HEAD ARRAY:
Part Numbe
r
Description Price HCPCS Code
I106805-99-0 Permobil Head Array - 3-Switch System 4,893.00 E2330
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.
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.
CHOOSE OCCIPITAL PAD SIZE (REQUIRED):
I105920-99-0 Small Occipital Pad for Head Array - 4.25"W x 3"H No Charge
I105921-99-0 Large Occipital Pad for Head Array - 6"W x 4"H No Charge
.
CHOOSE OCCIPITAL MOUNT (REQUIRED):
I10847 Fixed Mount for Head Array Occipital Pad No Charge
I105936-99-0 Adj. Swivel Mount for Head Array Occipital Pad 439.00 K0108
Enables Occipital Pad to be angled up/down and left/right independent of the lateral arms.
CHOOSE HEAD ARRAY MOUNT HARDWARE (REQUIRED):
I105927-99-0 Stealth TWB480 Backrest Mounting Hdwr with Links 293.00 E1028
Please select the length of the vertical stem below:
Standard length (10"): _____ Short length (6"): _____
I105941-99-0 Stealth TWB480 Backrest Mnt Hdwr with Flipback 473.00 E1028
I105925-99-0 Stealth HMO475 MultiAxis Backrest Mounting Hdwr 260.00 E1028
SELECT ADDITIONAL LEFT ARM PACKAGE (OPTIONAL):
I10976 Add Left Lateral Arm w Proximity Sensor 630.00
Choose Lateral Arm Adjustment Range:
Short (5.5" - 10"): ______ Long (5.5" - 14"): ______
I10977 Add Left Lateral Arm w Egg Switch 515.00
Choose Lateral Arm Adjustment Range:
Short (5.5" - 10"): ______ Long (5.5" - 14"): ______
I10978 Add Left Lateral Arm w Pad (No Sensor or Switch) 420.00
Choose Lateral Arm Adjustment Range:
Short (5.5" - 10"): ______ Long (5.5" - 14"): ______
SELECT ADDITIONAL RIGHT ARM PACKAGE (OPTIONAL):
I10979 Add Right Lateral Arm w Proximity Sensor 630.00
Choose Lateral Arm Adjustment Range:
Short (5.5" - 10"): ______ Long (5.5" - 14"): ______
I10980 Add Right Lateral Arm w Egg Switch 515.00
Choose Lateral Arm Adjustment Range:
Short (5.5" - 10"): ______ Long (5.5" - 14"): ______
I10981 Add Right Lateral Arm w Pad (No Sensor or Switch) 420.00
Choose Lateral Arm Adjustment Range:
Short (5.5" - 10"): ______ Long (5.5" - 14"): ______
Alt Drive Systems Setup
CHOOSE OMNI (REQUIRED):
Part Numbe
r
Description Price HCPCS Code
Page 17 of 19
Rev 2020-1 08/17/2020
F3 Corpus
Alt Drive Systems Setup
CHOOSE OMNI (REQUIRED):
Part Numbe
r
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
you will be using. Input Device:______________________________
I103476-99-0 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 Numbe
r
Description Price HCPCS Code
I10080 Mount Seat Control Switchbox on Backrest No Charge
Alt Drive Accessories
PERMOFIX MOUNTING SOLUTIONS:
Part Numbe
r
Description Price HCPCS Code
I106655-99-0 PERMOfix UniTrack Fixed Mount Kit 286.00
Includes two base joints, two 4" rods and one 8" rod.
I106656-99-0 PERMOfix UniTrack Removable Mount Kit 502.00
Includes quick release mount and thigh support hardware, two base joints and three different
length rods.
I106657-99-0 PERMOfix UniTrack Swing Away Mount Kit 719.00
Includes PERMOfix Swing Away module, two base joints, one 2" rod and one 4" rod.
I105907-99-0 Proximity Sensor + Swivel Assembly 363.00 E1028
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.
I105919-99-0 Egg Switch + Swivel Mount Assembly 245.00
Swivel assembly allows switch to be mounted with PERMOfix or directly to lateral arm of Total
Control Head Array.
I105912-99-0 Solid Oval Pad + Swivel Assembly 148.00
Swivel assembly allows pad to be mounted with PERMOfix or directly to lateral arm of Total
Control Head Array.
I106675-99-0 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 Numbe
r
Description Price HCPCS Code
I101769-99-0 Microlight Switch Qty:____ 198.00
I101767-99-0 Buddy Button Qty:____ 167.00
I106293-99-0 Egg Switch Black Qty: _____ 167.00
I101771-99-0 Mini Cup Switch Qty:____ 167.00
I107500-99-0 Proximity Switch Qty:____ 662.00
I107495-99-0 Mini Joyswitch 5 Switch OC for Omni - (9-pin) 718.00
I10772 Dome Switch, Backrest Mnt w Gooseneck Qty: _____ 524.00
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
clamp.
I10846 Dome Switch, Backrest Swg Awy Mnt w Gsneck Qty:____ 775.00 K0108
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.
I105935-99-0 3.5mm Ext. Cable for Sensor/Switch, 0.3m Long 33.00
Page 18 of 19
Rev 2020-1 08/17/2020
F3 Corpus
Alt Drive Accessories
OPTIONAL ITEMS:
Part Numbe
r
Description Price HCPCS Code
I105931-99-0 3.5mm Ext. Cable for Sensor/Switch, 1m Long 36.00
I105932-99-0 3.5mm Ext. Cable for Sensor/Switch, 2m Long 42.00
I105933-99-0 3.5mm Ext. Cable for Sensor/Switch, 3m Long 46.00
I105934-99-0 3.5mm Y-splitter Cable for Sensor/Switch 36.00
A
llows two Proximity Sensors/Mechanical Switches to connect to the same direction jack.
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.
Page 19 of 19
Rev 2020-1 08/17/2020
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