888-570-1113 Phone

866-514-1303 Fax

5096 South Service Road

Beamsville, ON L0R 1B3

pridemobility.com/

pridemobility.com/international/canada/

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Company:

Branch: Date:

Contact:

E-mail:

Phone: Fax:

TARTA Original Order Form

Stealth Products, LLC. | www.stealthproducts.com 1 P129D487R1 | July 25, 2017

Mobility Base Information Cane Sizes

Model Type

Frame Width

Frame Depth

Handle Height

Upper Back Cane

Lower Back Cane

Seat to Back Height

No Yes Rigidizer Bar

REQUIRED INFORMATION

Mark for: PO#:

A.

B.

C.

F.

G.

H.

I.

Sales Quote Sales Order

Rigidizer Bar Height

2

PACKAGE SELECTION (4 VERTEBRA)

TRTBS4A

Height Range

8”- 9”

Trunk Width Range

<10”

QTY.______

(4)TRT-RIB-S1

Rib Sequences Spine

(1)TRT-PAD-062

Pads

Package Includes

The following ribs and pads are also included

in the package to transform a standard active

back configuration into a DEEP contour back: (4)TRT-RIB-S2

(1)TRT-PAD-051

(2)TRT-PAD-056

(2)TRT-PAD-059

TRTBM4A

Height Range

8”- 9”

Trunk Width Range

10” - 12”

QTY.______

TRT-RIB-M4(4)

TRT-PAD-054(2)

(2)TRT-RIB-M1

Rib Sequences Spine

(1)TRT-PAD-062

Pads

Package Includes

The following ribs and pads are also included

in the package to transform a standard active

back configuration into a DEEP contour back:

(2)TRT-RIB-M3

(4)TRT-RIB-M2

(1)TRT-PAD-051

(2)TRT-PAD-056

(2)TRT-PAD-060

TRTBL4A

Height Range

8”- 9”

Trunk Width Range

12” - 14”

QTY.______

TRT-RIB-L4(2)

TRT-PAD-054(2)

(2)TRT-RIB-L1

Rib Sequences Spine

(1)TRT-PAD-062

Pads

Package Includes

The following ribs and pads are also included

in the package to transform a standard active

back configuration into a DEEP contour back:

(4)TRT-RIB-L3

(1)TRT-PAD-051

(2)TRT-PAD-057

TRTBX4A

Height Range

8”- 9”

Trunk Width Range

14” - 17”

QTY.______

TRT-RIB-X4(2)

TRT-PAD-054(2)

(2)TRT-RIB-X1

Rib Sequences

Spine

(1)TRT-PAD-062

Pads

Package Includes

(2)TRT-RIB-X2

(4)TRT-RIB-X3

(1)TRT-PAD-051

(2)TRT-PAD-058

(2)TRT-PAD-060

(2)TRT-PAD-060

TRT-RIB-S4(2)

TRT-PAD-053(2)

TRTBS4A Contour Configuration

Contour Configuration

Contour Configuration

The following ribs and pads are also included

in the package to transform a standard active

back configuration into a DEEP contour back:

Contour Configuration

The TRTBS4A package includes a mounting

hardware option in it’s price. Select on Page 5

Mounting Hardware

The TRTBM4A package includes a mounting

hardware option in it’s price. Select on Page 5

Mounting Hardware

The TRTBL4A package includes a mounting

hardware option in it’s price. Select on Page 5

Mounting Hardware

The TRTBX4A package includes a mounting

hardware option in it’s price. Select on Page 5

Mounting Hardware

MSRP: $1300.00

MSRP: $1300.00

MSRP: $1300.00

MSRP: $1300.00

(2)TRT-RIB-L2

3

PACKAGE SELECTION (5 VERTEBRA)

TRTBS5A

Height Range

10”- 11”

Trunk Width Range

<10”

QTY.______

TRT-RIB-S4(2)

TRT-PAD-053(2)

(4)TRT-RIB-S1

Ribs Spine

(1)TRT-PAD-062

Pads

Package Includes

The following ribs and pads are also included

in the package to transform a standard active

back configuration into a DEEP contour back: (6)TRT-RIB-S2

(2)TRT-PAD-051

(2)TRT-PAD-056

(2)TRT-PAD-059

TRTBM5A

Height Range

10”- 11”

Trunk Width Range

10” - 12”

QTY.______

Package Includes

TRTBL5A

Height Range

10” - 11”

Trunk Width Range

12” - 14”

QTY.______

Package Includes

TRTBX5A

Height Range

10”- 11”

Trunk Width Range

14” - 17”

QTY.______

Package Includes

(1)TRT-PAD-052

TRT-RIB-M4(2)

TRT-PAD-054(2)

(2)TRT-RIB-M1

Ribs Spine

(1)TRT-PAD-062

Pads

The following ribs and pads are also included

in the package to transform a standard active

back configuration into a DEEP contour back: (6)TRT-RIB-M2

(2)TRT-PAD-051

(2)TRT-PAD-056

(2)TRT-PAD-060

(1)TRT-PAD-052

(2)TRT-RIB-M3

TRT-RIB-L5(2)

TRT-RIB-L4(2)

TRT-PAD-054(2)

(6)TRT-RIB-L2

Ribs Spine

(1)TRT-PAD-062

Pads

The following ribs and pads are also included

in the package to transform a standard active

back configuration into a DEEP contour back: (4)TRT-RIB-L3

(2)TRT-PAD-051

(2)TRT-PAD-057

(2)TRT-PAD-060

(1)TRT-PAD-052

TRT-RIB-X4(2)

TRT-RIB-X5(2)

TRT-PAD-055(2)

TRT-PAD-061(2)

Spine

(1)TRT-PAD-062

Pads

The following ribs and pads are also included

in the package to transform a standard active

back configuration into a DEEP contour back: (2)TRT-PAD-051

(2)TRT-PAD-058

(2)TRT-PAD-060

(1)TRT-PAD-052

(2)TRT-RIB-X1

Ribs

(4)TRT-RIB-X2

(4)TRT-RIB-X3

Contour Configuration

Contour Configuration

Contour Configuration

Contour Configuration

The TRTBS5A package includes a mounting

hardware option in it’s price. Select on Page 5

Mounting Hardware

The TRTBM5A package includes a mounting

hardware option in it’s price. Select on Page 5

Mounting Hardware

The TRTBL5A package includes a mounting

hardware option in it’s price. Select on Page 5

Mounting Hardware

The TRTBX5A package includes a mounting

hardware option in it’s price. Select on Page 5

Mounting Hardware

MSRP: $1500.00

MSRP: $1500.00

MSRP: $1500.00

MSRP: $1500.00

4

PACKAGE SELECTION (6 VERTEBRA)

TRTBS6A

Height Range

12”

Trunk Width Range

<10”

QTY.______

TRT-RIB-S3(2)

TRT-RIB-S4(2)

TRT-PAD-053(2)

(6)TRT-RIB-S1

Ribs Spine Pads

Package Includes

The following ribs and pads are also included

in the package to transform a standard active

back configuration into a DEEP contour back: (6)TRT-RIB-S2

(1)TRT-PAD-051

(4)TRT-PAD-056

(2)TRT-PAD-059

TRTBM6A

Height Range

12” - 13”

Trunk Width Range

10” - 12”

QTY.______

Package Includes

TRTBL6A

Height Range

13”

Trunk Width Range

12” - 14”

QTY.______

Package Includes

TRTBX6A

Height Range

14”

Trunk Width Range

14” - 17”

QTY.______

Package Includes

(1)TRT-PAD-052

TRT-RIB-M4(2)

TRT-PAD-054(2)

TRT-PAD-057(2)

(4)TRT-RIB-M1

Ribs Spine

(1)TRT-PAD-062

Pads

The following ribs and pads are also included

in the package to transform a standard active

back configuration into a DEEP contour back: (6)TRT-RIB-M2

(1)TRT-PAD-051

(4)TRT-PAD-056

(2)TRT-PAD-060

(1)TRT-PAD-052

(2)TRT-RIB-M3

TRT-RIB-L4(2)

TRT-RIB-L5(2)

TRT-PAD-054(2)

(6)TRT-RIB-L2

Ribs Spine

(1)TRT-PAD-062

Pads

The following ribs and pads are also included

in the package to transform a standard active

back configuration into a DEEP contour back: (6)TRT-RIB-L3

(1)TRT-PAD-051

(4)TRT-PAD-057

(2)TRT-PAD-060

(1)TRT-PAD-052

TRT-RIB-X4(2)

TRT-RIB-X5(2)

TRT-PAD-055(2)

TRT-PAD-061(2)

Spine

(1)TRT-PAD-062

Pads

The following ribs and pads are also included

in the package to transform a standard active

back configuration into a DEEP contour back: (1)TRT-PAD-051

(2)TRT-PAD-058

(1)TRT-PAD-052

(4)TRT-RIB-X1

Ribs

(4)TRT-RIB-X2

(4)TRT-RIB-X3

Contour Configuration

Contour Configuration

Contour Configuration

Contour Configuration

The TRTBS6A package includes a mounting

hardware option in it’s price. Select on Page 5

Mounting Hardware

The TRTBM6A package includes a mounting

hardware option in it’s price. Select on Page 5

Mounting Hardware

The TRTBL6A package includes a mounting

hardware option in it’s price. Select on Page 5

Mounting Hardware

The TRTBX6A package includes a mounting

hardware option in it’s price. Select on Page 5

Mounting Hardware

MSRP: $1700.00

MSRP: $1700.00

MSRP: $1700.00

MSRP: $1700.00

(1)TRT-PAD-062

(2)TRT-PAD-057

5

TRT-RIB-S1 TRT-RIB-S2 TRT-RIB-S3 TRT-RIB-S4

QTY.______ QTY.______ QTY.______ QTY.______

TRT-RIB-L5

QTY.______

TRT-RIB-M1 TRT-RIB-M2 TRT-RIB-M3 TRT-RIB-M4

QTY.______ QTY.______ QTY.______ QTY.______

TRT-RIB-L1 TRT-RIB-L2 TRT-RIB-L3

QTY.______ QTY.______ QTY.______

TRT-RIB-L4

QTY.______

TRT-RIB-X1 TRT-RIB-X2 TRT-RIB-X3 TRT-RIB-X4

QTY.______ QTY.______ QTY.______ QTY.______

TRT-RIB-X5

QTY.______

MOUNTING HARDWARE SELECTION

SINGLE POINT FIXED

QTY.______

SINGLE POINTZ

ADJUSTABLE HEIGHT

QTY.______

2-POINT REMOVABLE

QTY.______

QTY.______

HEIGHT ADJUSTABLE

REMOVABLE MOUNT WITH BAR

ADDITIONAL STAVE SELECTION

SM-MED (TRTHW1AS)

LRG-XL (TRTHW1AL)

Includes 1 per package

SM-MED (TRTHW1FS)

LRG-XL (TRTHW1FL)

SM-MED (TRTHW1RS)

LRG-XL (TRTHW1RL)

SM-MED (TRTHW2RS)

LRG-XL (TRTHW2RL)

Stealth Products, LLC. | www.stealthproducts.com 6 P129D487R1 | July 25, 2017

TRT-PAD-062

4.5” X 7.5”

TRT-PAD-053

7” X 5”

TRT-PAD-054

8.5” X 5”

TRT-PAD-052

4.5” X 4.5”

CENTRAL & INTERMEDIATE PADS

TRT-PAD-055

9.5” X 5”

TRT-PAD-051

4.5” X 2”

TRT-PAD-056

5.5” X 4”

TRT-PAD-057

6” X 4.5”

TRT-PAD-058

7” X 5”

TRT-PAD-059

5” X 5”

TRT-PAD-061

8.5” X 5”

QTY.______ QTY.______ QTY.______ QTY.______

QTY.______QTY.______QTY.______QTY.______QTY.______

QTY.______

TRT-PAD-060

7” X 5”

QTY.______ QTY.______

ADDITIONAL PAD SELECTION

UPPER PADS

LOWER PADS

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.