alternative controls and electronics order form controls and electronics order form author robert...
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Page 1 of 4INFINFB3552/RevD/18JAN2018
This form is interactive when viewed with Adobe Acrobat Reader and may not function correctly if opened with applica-tions other than Acrobat. Complete the form by placing checks in the desired boxes and provide information in the interactive fields. Buttons shown at the bottom of the form may be utilized to print or submit the order form through a desktop email application. To email via a web-based application, please ‘Save As’ and attach the PDF to your email. Please contact Quantum Sales at 866-800-2002 if assistance is needed. Send the completed order form by fax (866-707-3422) or email ([email protected]). Incomplete forms may delay the quote or order. Customer service will contact you if the order is incomplete or if there are compatibility issues. 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. All prices are on-chair MSRP. Prices, specifications, part numbers, and availability are subject to change without notice.
Alternative Controls and Electronics Order Form
Quantum® Rehab401 York Ave., Duryea, PA 18642Phone: 866-800-2002 | Fax: 866-707-3422 | Email: [email protected]
Account Number: ___________ Date: ________________
Provider Name: __________________________________
Contact: ________________________________________
Phone: ___________________ Fax: _________________
Email: __________________________________________
PO Number: _____________________________________
Marked for: _____________________________________
Ship to Address: _________________________________
City: _____________________ State: ______ Zip: ______
Q-Logic 2 Sip & Puff Module .................. $1,895Part: KITASMB1697Select Sip & Puff component below.
Q-Logic 3 Sip & Puff Module .................. $1,895Part: CTL168056Select Sip & Puff component below.
SIP & PUFF CONTROLS
Additional AccessoriesSip & Puff Straws, 12 pack (SP625-S12) .... $32.10Part: ST-SP625-S12-Q
Sip & Puff Bus Cable .............................. $350Part: DWR1111H046
TRU-Balance 2 Power Recline ............... $50.57Accessory BracketPart: FRMASMB7322Allows cane mounted accessories to be mounted to a TRU-Balance 2 Recline system.
Sip & Puff Module
Stealth Sip & Puff
Stealth Sip & Puff
Stealth Sip and Puff for Comfort Series, .... $294.25Left Mount(SP625-CL)Part: ST-SP625-CL-Q Includes straw and mounting hardware. Use with Stealth Comfort Plus headrests.
Stealth Sip and Puff for Comfort Series, .... $294.25Right Mount (SP625-CR)Part: ST-SP625-CR-QIncludes straw and mounting hardware. Use with Stealth Comfort Plus headrests.
Stealth Sip and Puff for i-Drive Head ....... $294.25Array (SP625-U)Part: ST-SP625-U-Q Includes straw and mounting hardware. Use with Stealth i-Drive head arrays.
Sip & Puff Straws
ECU Kit for Q-Logic 2 ................................................................................................ $2,400Part: KITASMB1696 Includes ECU Module and Bus Cable.
ENVIRONMENTAL CONTROLS
Additional AccessoriesECU Bus Cable for Q-Logic 2 ................... $350Part: DWR1111H046
Q-Logic 2 Multiplier Harness ................$221.21Part: DWR1111H053Provides 2 additional bus connections.
ECU Module
QL3 Sip & Puff Module
Page 2 of 4INFINFB3552/RevD/18JAN2018
Account Number: ___________ Date: ________________ Marked for: _____________________________________
Mo-Vis™ All Round .............................. $1,575Joystick (IDM-ALLROUND-9)Part: ST-IDMALLRND9-Q May be used as chin, standard, or attendant joystick.
Mo-Vis™ Multi Joystick (IDM-MULTI-9) ......$3,229Part: STIDM-MULTI-9Q. HCPCS: E2312Designed to be controlled by the chin, finger, or lip.
Mo-Vis™ Micro Joystick (IDM-MICRO-9) .....$3,229Part: STIDM-MICRO-9Q. HCPCS: E2312Designed to be controlled by the finger, lip, or tongue. Supplied with 2 tips for driving option: a ball or cup mount.
Stealth Precision Mini Proportional .........$3,229Joystick (IDPMP-9)Part: ST-IDPMP-9-Q. HCPCS: E2312Designed to work for users with minimal range of motion and strength. Additional tops available through SOF.
Stealth Mushroom Joystick ................... $1,995(MJM250Q)Part: ACCASMB2380
Stealth Gatlin Mount, Cane Mount, ....... $603.75for Chin Control (A) (GAT406C)Part: FRMASMB8304Includes a receiver block for tube-style mounting.
Stealth Gatlin Midline Mount (B) ........... $603.75(GAT400Q)Part: ST-GAT400Q-Q Requires a receiver block, not included.
Stealth Gatlin Mount Bracket for ...........$183.75Stand Alone Joystick (GAT452CJ)Part: ST-GAT452CJ-Q
Stealth Gatlin Mount Bracket for ...........$183.75Mini Proportional Joystick (GAT486)Part: ST-GAT486-Q
Stealth Gatlin Mount Bracket for ...........$183.75NE, NE+, or Q-Logic (GAT456QL)Part: ST-GAT456QL-Q
Stealth Gatlin Mount Bracket for ...........$183.75Enhanced Display (GAT454ED)Part: ST-GAT454ED-Q
Stealth Gatlin Mount Bracket for ...........$183.75Mo-Vis All Round Joystick (GAT472P-M)Part: ST-GAT472P-M
Stealth Gatlin Mount Bracket for ...........$183.75Mo-Vis Multi Joystick (GAT461M)Part: ST-GAT461M-Q
Stealth Gatlin Mount Bracket for ...........$183.75Mo-Vis Micro Joystick (GAT451M)Part: ST-GAT451M-Q
PROPORTIONAL SECONDARY CONTROLS
Mini Proportional
Mo-Vis Joysticks
Mushroom Joystick
Mo-Vis™ Joysticks
Stealth Joysticks
Stealth Gatlin Mounts and BracketsGatlin Mount
Gatlin Mounting Bracket
Chin
Midline
Gatlin Mounts
Tray Mount for Mo-Vis Micro Joystick .... $472.50Left Side Control (GAT440M-51M-L)Part: ST-GAT44051ML-Q
Tray Mount for Mo-Vis Micro Joystick .... $472.50Right Side Control (GAT440M-51M-R)Part: ST-GAT44051MR-Q
Stealth Adjustable Tray and Bracket
Tray, Right Side Control
Swing-Away Joystick Mount for Micro .....$157.50Joystick (SM600-651) (B)Part: ST-SM600-651-Q
Swing-Away Joystick Mount for Multi .....$157.50Joystick (SM600-661) (C)Part: ST-SM600-661-Q
Swing-Away Joystick Mount for ............. $157.50Precision Mini Proportional Joystick (SM671) (D)Part: ST-SM671-Q
Swing-Away Joystick Mount with 18" Rod (A) .....................................................................$250Part: ST-SUS18-QAttaches to the Stealth Comfort Series headrests.
Swing-Away Mount
Brackets for Swing-Away MountThese brackets mount a joystick to the Swing-Away Joystick Mount with 18" rod or similar hardware.
Stealth Swing-Away Mounts and Brackets
Stealth Swing-AwayJoystick Mounts
Page 3 of 4INFINFB3552/RevD/18JAN2018
TRU-Balance 2 Power Recline Accessory Bracket ......$50.57Part: FRMASMB7322Allows cane mounted accessories to be mounted to a TRU-Balance 2 Recline system.
Therafin Softline Bridge and Collar (32685) ............... $310Part: INDPART2152
Therafin Semi-Rigid Bridge and Collar (32669) ............ $227Part: INDPART2895
Midline/ Bib MountsOther Mounts/Brackets
Adult, i-Drive Tri-Array Series, 3-Switch .. $4,414Head Array (IDHBT200-1)Part: ST-IDHBT200-1-Q. HCPCS: E2330Features bluetooth, head support, 3 non-proportional proximity sensors for drive control, an egg switch for re-set mode change, and i-Drive smart box.
Adult, i-Drive Pro Series Head Array ....... $4,461(IDHBT300-1)Part: ST-IDHBT300-1-Q. HCPCS: E2330Features bluetooth, head support with occipital pad and 2 swing-away spot pads for left and right side, 3 non-pro-portional proximity sensors, an egg switch for reset mode change, and i-Drive smart box.
HEAD ARRAYS
Account Number: ___________ Date: ________________ Marked for: _____________________________________
PROPORTIONAL SECONDARY CONTROLS continued
Adult Pro-Series
Yellow Twister Basic Button (IDM-24) ........ $289Part: ST-IDM-24-Q
Black Twister Basic Button (IDM-25) .......... $289Part: ST-IDM-25-Q
Red Twister Basic Button (IDM-26) ............ $289Part: ST-IDM-26-Q
Blue Twister Basic Button (IDM-27) ........... $289Part: ST-IDM-27-Q
Green Twister Basic Button (IDM-28) ......... $289Part: ST-IDM-28-Q
Mo-Vis™ Twister Basic SwitchSingle input, mechanical button switch with light activation force activated at any point on the switch.
Twister Basic
Red Egg Switch (ESRED) .......................$80.85Part: SWTMCRO1077
Green Egg Switch (ESGRN) ....................$80.85Part: SWTMCRO1078
Blue Egg Switch (ESBLU) ......................$80.85Part: SWTMCRO1079
Yellow Egg Switch (ESYEL) ....................$80.85Part: SWTMCRO1080
Black Egg Switch (ESBLK) .....................$80.85Part: SWTMCRO1081
SINGLE SWITCHESStealth Egg Switches
Egg Switch
Red Twister Satellite Button (IDM-17) .........$415Part: ST-IDM-17-Q
Black Twister Basic Button (IDM-18) ...........$415Part: ST-IDM-18-Q
Yellow Twister Basic Button (IDM-19)..........$415Part: ST-IDM-19-Q
Blue Twister Satellite Button (IDM-20) ........$415Part: ST-IDM-20-Q
Green Twister Satellite Button (IDM-21) ......$415Part: ST-IDM-21-Q
Mo-Vis™ Twister Satellite ButtonsSingle input, mechanical button switch with light activation force activated at any point on the switch. The Satellite Twister and its attached bracket only fits into the housing of the the All-Round Joystick.
Twister Satellite
Mini Cup Switch w/ Stickers (58080) ........... $75Part: SWTMCRO1064
Black Spec Switch (100-SPBK).................... $65Part: SWTMCRO1116
Yellow Spec Switch (100-SPY) .................... $65Part: SWTMCRO1115
Ablenet Round SwitchSingle input, mechanical button switch. Includes 5 stickers.
Ablenet Spec SwitchSingle input, mechanical button switch. Includes 5 stickers.
Spec Switch
Round Switch
Page 4 of 4INFINFB3552/RevD/18JAN2018
Micro Light Switch (58500) ....................... $85Part: SWTMCRO1044
Pillow Switch (58750) .............................$125Part: SWTMCRO1052
Ablenet Micro Light SwitchSingle input, feather touch, mechanical button switch.
Ablenet Pillow SwitchSingle input, feather touch, mechanical button switch with a smooth, soft surface.
Micro Light Switch
Pillow Switch
Single Switch Extension, 6' ......................................$30(Abelnet:43330)Part: INDPART2824
4-Switch to AAM Adapter ........................................$65Part: DWR1265H064 Allows 4 separate mechanical switches to be connected to AAM to control seat functions.
5 to 1 Switch Adapter ...................................... $310.59Part: HARUSHD2101Connects up to 5 single switches to connect to 1 9-pin (DB9) connec-tion to act as a multiple switch device.
2 to 1 Switch Adapter ........................................$13.39Part: DWR1361H037 Connects 2 single switches to a stereo jack to act as a dual switch.
SINGLE SWITCH ACCESSORIES
Account Number: ___________ Date: ________________ Marked for: _____________________________________
SINGLE SWITCHES
Powertech LTV Style Vent Power Module Kit ........... $2,220Part: ELEASMB7110034. HCPCS: K0108Powers a LTV style vent from the wheelchair's batteries. Includes compatible components below.
Powertech Trilogy Vent Power Module Kit .............. $2,220Part: ELE143268. HCPCS: K0108Powers a Trilogy vent from the wheelchair's batteries. Includes com-patible components below.
Powertech Vent Module (06076) ...........................$1,950Part: CTLDC8110005
Powertech Vent Harness, 12V Output (060770) .......... $150Part: HAR8110009
Powertech Vent Harness, 24V Input (060774) ............ $120Part: HAR8110008
Powertech Trilogy Vent Harness, 12V Output ............. $150(060771)Part: ELE143265
POWERTECH VENT POWER MODULE
Individual Selections
Q-Logic 2 USB Mobile Device Charger .........$175Part: ELE124122
Q-Logic 3 USB Mobile Device Charger .........$175Part: ELE168069
USB CHARGER WITH MOUNTING HARDWAREThe USB charger module can be connected anywhere on the system bus and provides a dedicated charging port for mobile devices according to USB Battery Charging Specifications Revision 1.2. It is intended to charge only one device at a time at a current of 1A or less. The USB char-ger module is not to be used with passive USB hubs or splitters.
USB MediaDevice Charger
©2017 Quantum Rehab - A Pride Mobility Products Corporation company. All rights reserved.
Quantum® Rehab401 York Ave., Duryea, PA 18642Phone: 866-800-2002 | Fax: 866-707-3422 | Email: [email protected]
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