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Page 1 of 7INFINFB4067/RevC/01OCT2019
Red CorvettePart: DGN1900533-PRD1
Electric BluePart: DGN1900533-PBU9
Back in BlackPart: DGN1900533-PBK1
J4 Order Form with Power Positioning SeatingAccount Number: ___________ Date: ________________
Provider Name: __________________________________
Contact: ________________________________________
Phone: ___________________ Fax: _________________
Email: __________________________________________
PO Number: _____________________________________
Marked for: _____________________________________
Ship to Address: _________________________________
City: _____________________ State: ______ Zip: ______
Weight:________ Height:________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
A. Shoulder Width: ________B. Chest Width: ___________C. Hip Width: _____________
D. Max Sitting Height: ______E. Shoulder Height: ________F. Axilla Height: __________
G. Thigh Depth: ___________H. Lower Leg Length: ______I. Elbow Height: __________
This form is interactive when viewed with Adobe Acrobat Reader and may not function correctly if opened with applications other than Acrobat. Com-plete 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. This order form contains a large variety of options to fulfill various patient needs. Descriptions and section notes, such as optional or required, are included to help you complete your order. 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. If special order requests are needed, be sure that the Patient Information section is completed or include a completed physical assessment form with this order form. HCPCS codes provided should not be considered as legal advice and do not guarantee reimbursement. DME providers are responsible for deter-mining the appropriate billing codes when submitting for insurance reimbursement. Payer coding, coverage, and bundling guidelines may apply. All prices are MSRP. Prices, specifications, part numbers, and availability are subject to change without notice. Prices and part numbers as shown are only available when configured as a complete power chair. Please contact technical service for accurate parts ordering. Options noted with "XRef" have multiple possible part numbers based on system configuration. Please see cross-reference spreadsheet for the XRef part numbers.
Thank you for choosing Quantum!
INTRODUCTION
PATIENT INFORMATION
1. BASE MODELREQUIRED. 300 lb. weight capacity with standard 5 mph programmable motors, 8 amp off board charger, and flat free drive wheels. Dimensions of base without legrests: 24.5”Wx32.3”L.
Quantum J4 2SP-SS ..................................................................................................................................................... $6,995Part: J4 2SP-SS. HCPCS: K0835Single power option.
2. BASE COLORREQUIRED. Select one shroud color. Colors shown here may differ from actual product depending on monitor/printer calibration used.
Quantum® Rehab401 York Ave., Duryea, PA 18642Phone: 866-800-2002 | Fax: 866-707-3422 | Email: [email protected]
https://get.adobe.com/reader/http://www.quantumrehab.com/resources/downloadorderforms.php?f=seating/us_physical_assessment_form.pdfhttp://www.quantumrehab.com/resources/downloads/order_forms/order_forms.asp
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Page 2 of 7INFINFB4067/RevC/01OCT2019
3. BASE MOUNTED FOOT PLATFORMREQUIRED. May interfere with seat mounted legrests.
Account Number: ___________ Date: ________________ Marked for: _____________________________________
7. ELECTRONICSREQUIRED.
Base Mounted Foot Platform ...................................... StandardPart: FRMASMB16077
Omit base mounted foot platform ............................. No ChargePart: PTOINDV3674
NE 4-Key Joystick .................................................... StandardPart: CTLDC1554For use with Tilt only through toggle.
NE+ 6-Key Joystick ................................................ No ChargePart: CTLDC1560Controls up to two actuators.
Expandable controls are special order, please contact your inside sales representative.
Mushroom Handle (B) ..................................... $85Part: ACCASMB1860. HCPCS: E2323
Chin Cup (C) ................................................. $85Part: ACCASMB1861.HCPCS: E2323. (E2324 when chin control)
T-Bar (D) .................................................... $120Part: ACCASMB1858. HCPCS: E2323
Medium Ball Handle (E) ................................... $65Part: ACCASMB1859. HCPCS: E2323
Soft Ball Handle (F) ........................................ $65Part: ACCASMB1856. HCPCS: E2323
Extended I-Handle (G) .................................... $85Part: ACCASMB1857. HCPCS: E2323
Bodypoint 3” Goal Post Handle ......................... $99Part: PLSKNCP1057. HCPCS: E2323
Bodypoint 4” Goal Post Handle ......................... $99Part: PLSKNCP1058. HCPCS: E2323
Joystick Handles
9. JOYSTICK HANDLESOptional. The joysticks are standard with a carrot handle (See A in image). The optional handle will be mounted to the joystick and the standard handle will be shipped with the unit.
8.1b. Swing-Away (Retractable) Joystick BracketAllows the joystick to retract to the side of the armrest while maintaining the same joystick orientation.
Swing-away, Inline, Left Side Mount ..................$245Part: ACC142526. HCPCS: E1028
Swing-away, Inline, Right Side Mount ................$245Part: ACC142527. HCPCS: E1028
8.1a. Fixed, In-line Joystick BracketFixed, In-line, Bracket .............................................................................................................StandardPart: FRMASMB12744
Left Side MountPart: PTOINDV1225
Right Side MountPart: PTOINDV1226
Swing Away JoystickInline Mount (Right)
8. JOYSTICK MOUNTING BRACKETSOptional. Select a mount to be used with a joystick selected in previous section.
4. BATTERIESREQUIRED. The powerchair requires 2 batteries and will be installed if ordered.
6. SEAT TO FLOOR HEIGHTREQUIRED.
NF-22, Gel Cell, Interceptor Battery..............................................................................................................................$330 ea.Part: BAT1704613. HCPCS: E2361
5. TRANSIT OPTIONSOptional. The power base is standard without transit securement.
Unoccupied Transit ........................................................$175Part: KIT130229Allows the powerchair to be secured for unoccupied transit.
WC-19 Occupied Transit Option ........................................ $275Part: KIT152047To determine if your chair is WC-19 compliant (occupied), please re-fer to this website: http://wc-transportation-safety.umtri.umich.edu/crash-tested-product-lists/wheelchairs
7.1b. Expandable Controls
7.1a. Non-Expandable Controls
10.1. Q4 Seat Configuration
10.2. Seat Dimension - WidthREQUIRED. Maximum seat width is 20". Width package range will be 16"-20" wide.
10. POWER POSITIONING SEATINGREQUIRED.
16” WidePart: SETWDTH1006
18” WidePart: SETWDTH1008
20” WidePart: SETWDTH1010
Q4 Seat Power Tilt Only ................................................................................................................................................ $5195Part: PTOINDV3882. HCPCS: E100255° Center of Gravity (CG) power tilt seating system.
Power positioning seating section continued on following pages.
17.25" STFPart: PTOINDV3558
18.25" STFPart: PTOINDV3559
19.25" STFPart: PTOINDV3560
http://wc-transportation-safety.umtri.umich.edu/crash-tested-product-lists/wheelchairshttp://wc-transportation-safety.umtri.umich.edu/crash-tested-product-lists/wheelchairs
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Page 3 of 7INFINFB4067/RevC/01OCT2019
10.6. Back Cane TypeREQUIRED.
Angle Adjustable ................................................... No ChargePart: MEC140266
Flip Forward ............................................................... $150Part: MEC140272
10.5. Seat CushionOptional. Specific cushion/component sizes available, part numbers, weight capacities, and special order cushions can be found on the respective complete Stealth Cushion Order Forms. This images are direct hyperlinks. This section allows a quick selection of a single cushion. The XXYY portion of the part number directly relates to the dimensions of the cushion, where XX represents the width and YY represents the depth. 1. Seat Cushion Model Selection
TRU-Comfort 2 SPP, E2607, 16"W to 20" W .........$400Simplicity G, E2601, 16"W to 20" W ................... $110
Solution SPP, E2607, 16"W to 20" W ..................$375
Spectrum Gel SPP, E2607, 16"W to 20" W ...........$460Spectrum Foam SPP, E2607, 16"W to 20" W .........$460
Stealth Simplicity G CushionGeneral use cushion with Stealth Tek 2, 2-way stretch, breathable cover.Part series: ST-SIMGXXYY
Stealth Solution SPP CushionSkin protection and positioning with Coolcore, 4-way stretch, breathable cover. Includes urethane liner.Part series: ST-SOLSPPXXYY
Stealth Spectrum Gel SPP CushionSkin protection and positioning with Coolcore, 4-way stretch, breathable cover. Includes urethane liner.Part series: ST-SPCGSPPXXYY
Stealth TRU-Comfort 2 SPP CushionSkin protection and positioning with Coolcore, 4-way stretch, breathable cover.Part series: ST-TC2SPPXXYY
Stealth Spectrum Foam SPP CushionSkin protection and positioning with Coolcore, 4-way stretch, breathable cover. Includes urethane liner.Part series: ST-SPCFSPPXXYY
Premiere P, E2605, 16"W to 20" W ....................$325
Stealth Premiere P CushionPositioning with Coolcore, 4-way stretch, breathable cover.Part series: ST-PREMPXXYY
Glacial SP, E2603, 16"W to 20"W ......................$330
Stealth Glacial SP CushionSkin protection with Coolcore, 4-way stretch, breathable cover.Part series: ST-GLSPXXYY
Fluid Proof Urethane Liner ......................................... $50-$70Part: URL1709070-XXYYNot available with Simplicity, Essence, or TRU-Comfort 2.
Fluid Proof Polyurethane Liner .................................... $55-$75Essence/TC2 part: PUL1709080-XXYY. Others part: PUL1709030-XXYYNot available with Simplicity.
Match Seat Width and Depth
16" W 18" W 20" W 16" D 18" D 20" D 22" D
Cushion Width Cushion Depth
2. Seat Cushion DimensionsREQUIRED with cushion model selection. Select to match or pick non-matching dimensions. See respective cushion order form for available sizes.
3. Seat Cushion Substitute/Add Fluid Proof Liners
Stealth Tek 2 Cover ................................................ No ChargePart: *prefix-TBLKXXYYNot available with Simplicity, TRU-Comfort 2, Essence, or Premiere.
Mesh Cover .......................................................... No ChargePart: *prefix-MBLKXXYYNot available with Simplicity or TRU-Comfort 2.
4. Seat Cushion Substitute CoverThe standard cover may be substituted by checking an option below. The "*prefix" of the part number will be the part prefix of the cushion model selected above. For example, SPCGSPP-NBLK1816 will be an additional coolcore cover for a Spectrum Gel cushion.
10.3. Seat Dimension - DepthREQUIRED. Maximum seat depth is 22".
16” DeepPart: SETDPTH1006)
18” DeepPart: SETDPTH1008
20” DeepPart: SETDPTH1010
22” DeepPart: SETDPTH1012
Account Number: ___________ Date: ________________ Marked for: _____________________________________
Power positioning seating section continued on following pages.
10.4. Seat Dimension - Depth PackageREQUIRED. Part: See XRef: TB3SPACK
16”-20” Depth PackagePart if WC-19: SET160461, else part: SET160209
20”-24” Depth PackagePart if WC-19: SET1805288, else part: SET160210
10. POWER POSITIONING SEATING continued
Stealth Essence SPP CushionSkin protection and positioning with Coolcore, 4-way stretch, breathable cover.Part series: ST-ESSSPPXXYY
Zen SP, E2603, 16"W to 22" W .......................... $315
Stealth Zen SP CushionSkin protection with Coolcore, 4-way stretch, breathable cover.Part series: ST-ZENSPXXYY
Essence SPP, No Wedge, 16"-20" Wide, E2607 ........$400Essence SPP, Small Wedge, 16"-20" Wide, E2607 .... $435Essence SPP, Medium Wedge, 16"-20" Wide, E2607 . $465Essence SPP, Large Wedge, 16"-20" Wide, E2607 .... $495
10.7. Back Cane HeightREQUIRED.
16”H CanePart: FRMASMB15834
17”H CanePart: FRMASMB15835
20”H CanePart: FRMASMB15838
21”H CanePart: FRMASMB15839
24”H CanePart: FRMASMB15842
25”H CanePart: FRMASMB15843
https://www.quantumrehab.com/resources/quantum-order-forms.asphttps://www.quantumrehab.com/resources/quantum-order-forms.asphttps://www.quantumrehab.com/pdf/order-forms/seating/us_stealth_simplicity_order_form.pdfhttps://www.quantumrehab.com/pdf/order-forms/seating/us_stealth_spectrum_foam_order_form.pdfhttps://www.quantumrehab.com/pdf/order-forms/seating/us_stealth_solution_order_form.pdfhttps://www.quantumrehab.com/pdf/order-forms/seating/us_stealth_trucomfort_2_order_form.pdfhttps://www.quantumrehab.com/pdf/order-forms/seating/us_stealth_spectrum_gel_order_form.pdfhttps://www.quantumrehab.com/pdf/order-forms/seating/us_stealth_glacial_order_form.pdfhttps://www.quantumrehab.com/pdf/order-forms/seating/us_stealth_premiere_order_form.pdf
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Page 4 of 7INFINFB4067/RevC/01OCT2019
2-Post, Flip Back, Height Adjustable, and Removable Armrests (9”-13” Height) .......................................................................$150 ea.Part: See XRefRequired with flip forward back and lap trays.
Lateral Extension for Synergy Back (pair) .................................................................................................................... $26.25 ea.16"OH back part: FRMASMB16274. 17"OH back part: FRMASMB16280. 20"&21"OH back part: FRMASMB16298. 24"&25"OH back part: FRMASMB16281
11.1b. Two-Post, Height Adjustable, Removable ArmrestsSelect the armrest and set the left and right heights in the following section. These armrests may interfere with offset backs/ back canes.
11.1a. Drop-In, Height Adjustable, Removable ArmrestsIncludes straight armpads. Do not select options from armrest size nor armpads sections.
Full Length, Drop-In Armrests (9"-14" Height) .......... No ChargeLeft part: ARM1803253. Right part: ARM156742
Desk Length, Drop-In Armrests (9"-14" Height) ......... No ChargeLeft part: ARM1803254. Right part: ARM156743
11.2. Armrest HeightREQUIRED with two-post armrest selection. Set left and right armrest height.
9” HPTOINDV3536
10” HPTOINDV3537
11” HPTOINDV3538
12” HPTOINDV3539
13” HPTOINDV3540
9” HPTOINDV3451
10” HPTOINDV3452
11” HPTOINDV3453
12” HPTOINDV3454
13” HPTOINDV3455
1. Left Armrest Height
2. Right Armrest Height
Account Number: ___________ Date: ________________ Marked for: _____________________________________
17” HeightPart: SETHGHT1030
20” HeightPart: SETHGHT1033
21” HeightPart: SETHGHT1034
24” HeightPart: SETHGHT1037
25” HeightPart: SETHGHT1038
10.10. Overall Back Cushion HeightREQUIRED with Synergy back selection. Odd heights include 4” gap and even heights include 3” gap between seat pan and bottom of back cushion.
10.11. Lateral ExtensionsREQUIRED with thoracic lateral selections.
11.3. Armrest SizeREQUIRED with two-post armrest selection. Select a left (L) and right (R) armrest size. This also affects armpad selection.
10” LengthPart: Configuration selection
14” LengthPart: Configuration selection
Straight Armpads .....................StandardPart: See XRef
Waterfall Armpads ................. No ChargePart: See XRef
No Armpad Selection ............. No ChargePart: PTOINDV1373
11.4. TRU-Balance ArmpadsREQUIRED with two-post armrest selection. Waterfall armpads may cause interference with the seat back. Armpads are configured as pairs.
60” Lap BeltPart: ACCBELT1002
60” Sure-Lok Lap Belt (Non-retractable) ............................ $120Required with ISO 7176-19 Compliant Transit Option.Part: ACCBELT1016
13. LAP BELTREQUIRED.
12.1. Headrest Pads
12.2. Headrest BracketsStealth Multi-Axis Removable Headrest Bracket (HMO475P) .................................................................................................$160.50Part: HDWASMB1084. HCPCS: E1028
Stealth Large Contoured (11”Wx6”H) (STL-OTLG150) ............ $80.25Part: SETHEAD1053. HCPCS: E0955
Stealth 8” Comfort Plus (CP450) ....................................$151.94Part: POS148484. HCPCS: E0955
Stealth 10” Comfort Plus (CP250) ..................................$151.94Part: SETHEAD1057. HCPCS: E0955
11. Q4 SEAT ARMRESTSREQUIRED. Left (L) and right (R) boxes may be checked to configure different size arms within one section arm type.
12. HEADRESTSOptional. Select a headrest pad and bracket.
10.9. Back ShroudREQUIRED. The back shroud is not available when Omit Back Pan/Cushion is selected. Reference colors shown on page 2.
Red CorvettePart: DGN148034
Back in BlackPart: DGN148032
Electric BluePart: DGN148076
10. POWER POSITIONING SEATING continued10.8. Back Cushion TypeREQUIRED.
Synergy Back ........................................................ No ChargePart: See XRef
Omit Back Pan/Cushion ........................................... No ChargePart: PTOINDV1287
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Page 5 of 7INFINFB4067/RevC/01OCT2019
Account Number: ___________ Date: ________________ Marked for: _____________________________________
14. POWER POSITIONING ELECTRONICSREQUIRED.
14.1a. Tilt Only through Toggle
14.1b. Power Positioning through JoystickSingle Actuator Control Through NE+ Joystick ................... $1,895Part: ELE130744. HCPCS: E2310
Two Actuator Control Through NE+ Joystick .....................$2,895Part: ELE130747. HCPCS: E2311
Small Calf Pads (pair) 6”Wx6”H ................................. No ChargePart: RIGASMB7120018
Large Calf Pads (pair) 8” taper to 6”Wx8”H ................. No ChargePart: RIGASMB7120019
10"-16" Extension, 5"x6" FootplatesPart: RIG150206Not available with power articulating platform.
10"-16" Extension, 5"x8" FootplatesPart: RIG150203Not available with power articulating platform.
10"-16" Extension, 5"x11" FootplatesPart: RIG150212
13"-19" Extension, 5"x6" FootplatesPart: RIG151505
13"-19" Extension, 5"x8" FootplatesPart: RIG151506
13"-19" Extension, 5"x11" FootplatesPart: RIG151508
Power Articulating Foot Platform .................. $2,995Part: PTOINDV3754. HCPCS: E1012
Manually Adjustable Center Mount .............. No ChargeFoot PlatformPart: RIG1710345
15.1. Center Mount Foot PlatformIf power articulating foot platform is selected, be sure power legrest control has been selected in earlier section. Select legrest length in following section.
2. Lower Extension and Angle Adjustable Footplates
1. Foot Platform Assembly
3. Center Mount Calf SupportCalf pad and panel covers include 1/2” of soft visco foam.
Power ArticulatingFoot Platform
Legrests section continued on following page.
Width Extension for 8”D Footplates ...................................$50Part: RIG152517
Width Extension for 11”D Footplates ..................................$50Part: RIG152518
2” Bell-Shaped Length Extension .......................................$50Part: RIG152519Not compatible with width extensions. Can be used with 6” outside edge with 11” footplates.
4” Outside Edge (pair) .....................................................$50Part: RIG152510Only available with 6”D footplates and 8”D footplate extension.
6” Outside Edge (pair) .....................................................$50Part: RIG152516Available with 8”D and 11”D footplates and 11”D footplate extension.
Reversed Dartex Calf Pad Cover (pair) ............................... $150Small part: RIG133717. Large part: RIG133719
Reversed Dartex Panel Cover (pair) .................................. $150Small part: RIG134673. Large part: RIG134744
Wheel Bumpers (pair) ............................................. $12.50 ea.Part: WHLASMB1578 x2
Footplate Connector ....................................................... $15Part: RIGASMB7120023
4. Modular Footplate Extension ComponentsOptional. Assembly required. May require seating configuration adjustments to avoid front caster interference.
5. Additional Accessories
60°-90° Swing-Away Legrest ........................... No ChargePair part: RIG120062. Left: FRMASMB17558. Right: FRMASMB17559Not available with 11"-13" extensions.
60°-90° Swing-Away Legrest, Short .................. No ChargePair part: RIG136481. Left: RIG132607. Right: RIG132609.For use only with 11"-13" lower extensions.
15.2. Swing-Away LegrestsSelect a legrest upper, a legrest extension, and type of footplate. Pair (P), left (L), and right (R) configurations are selected by checking the appropriate boxes.1a. 60°-90° Swing-Away Legrest UppersAdjustable in 5° increments.
70° Swing-Away Legrest (pair) ...................................................................................................................................No ChargePair part: FRMASMB7841Not available with 11"-13" extensions.
1b. 70° Swing-Away Legrest UppersOnly available with occupied transit WC-19 selections. Sold only in pairs. Select lower extension and footplates as pairs.
11”-13” LengthPart: See XRefN/A with Multi-axis.
11”-16.5” LengthPart: See XRefN/A with Angle Adj.
13”-16.5” LengthPart: See XRefN/A with Multi-Axis.
15.5”-19.5” LengthPart: See XRef
2. Lower Extension
15. LEGRESTSOptional. All efforts will be made to accommodate legrest length selection, but minor changes may need to be made to meet shipping guidelines. Some adjustments may be needed upon receipt of the unit. Reference the section’s compatibility matrix for legrest interference.
Single Actuator Control, Power Tilt Only, Through Toggle (NE 4-Key Joystick Only) ................................................................No ChargePart: ELE1905907Select toggle side. May require extended lead time when selected with Fender Lights.
Left Side Toggle Right Side TogglePart: PTOINDV1839 Part: PTOINDV1838
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Page 6 of 7INFINFB4067/RevC/01OCT2019
Account Number: ___________ Date: ________________ Marked for: _____________________________________
3b. Angle Adjustable Footplate(s)¹The 6”x11” footplates may cause interference with seat widths less than 18”. ²The 8”x11” footplates may cause interference with seat widths less than 20”.
4”Wx6”D .......................................................$85 ea.Pair part: FRMASMB10564. Left: RIG133537. Right: RIG133560
5”Wx6”D........................................................$85 ea.Pair part: FRMASMB10565. Left: RIG133538. Right: RIG133561
5”Wx8”D .......................................................$85 ea.Pair part: FRMASMB10566. Left: RIG133539. Right: RIG133562
6”Wx8”D1 ......................................................$85 ea.Pair part: FRMASMB10567. Left: RIG133540. Right: RIG133563
6”Wx11”D1 .....................................................$85 ea.Pair part: FRMASMB10568. Left: RIG133541. Right: RIG133564
8”Wx11”D2 .....................................................$85 ea.Pair part: FRMASMB10569. Left: RIG133542. Right: RIG133565
3a. Extruded Footplate(s)7.25”Wx6”D Extruded Footplate ........................ StandardPart pair: FRMASMB7847. Left: FRMASMB7861 Right: FRMASMB7862
8.5”Wx6”D Extruded Footplate ......................... StandardPart pair: FRMASMB7848. Left: FRMASMB7863 Right: FRMASMB7864May cause interference on seat widths less than 18.”
3c. Multi-Axis Footplate(s)¹The 6”x11” footplates may cause interference with seat widths less than 18”. ²The 8”x11” footplates may cause interference with seat widths less than 20”.
4”Wx6”D ................................................. $247.50 ea.Pair part: FRMASMB9456. Left: RIG133531. Right: RIG133552
5”Wx6”D.................................................. $247.50 ea.Pair part: FRMASMB9457. Left: RIG133532. Right: RIG133553
5”Wx8”D ................................................. $247.50 ea.Pair part: FRMASMB9458. Left: RIG133533. Right: RIG133554
6”Wx8”D1 ................................................ $247.50 ea.Pair part: FRMASMB9459. Left: RIG133534. Right: RIG133555
6”Wx11”D1 ............................................... $247.50 ea.Pair part: FRMASMB9460. Left: RIG133535. Right: RIG133558
8”Wx11”D2 ............................................... $247.50 ea.Pair part: FRMASMB9461. Left: RIG133536. Right: RIG133559
4. Swing-Away Legrest Accessories
5. Amputee Supports with Swing-Away UpperEnter a quantity for the amputee supports and covers. A 60°-90° legrest upper must be selected with the amputee support. The support will be configured with the legrest upper side that does not have a lower extension and footplate selected with it.
Heel Loops (pair) ............................................................$50Part: FRMASMB7873. HCPCS: E0951Standard on angle adjustable and multi-axis footplates.
Wheel Bumper ...................................................... $12.50 ea.Part: See XRef
Gel Neoprene Footrest Sleeve (pair) ...................................$80Part: INDPART2243. HCPCS: K0108
Therafin 31515 Multi-Axis Amputee Support ............. $230 ea.Part: INDPART2822. HCPCS: E1020
Therafin 32387 Amputee Support Gel Cover ..............$155 ea.Part: INDPART2823. HCPCS: K0108
15. LEGRESTS continued
11” L(#3478)
11.5” L(#3479)
12” L(#3480)
12.5” L(#3481)
13” L(#3482)
13.5” L(#3483)
14” L(#3484)
14.5” L(#3485)
15” L(#3486)
15.5” L(#3487)
16” L(#3488)
16.5” L(#3489)
17” L(#3490)
17.5” L(#3491)
18” L(#3492)
18.5” L(#3493)
19” L(#3494)
19.5” L(#3495)
Oxygen Holder ............................................................. $200Part: ACC125006 HCPCS: E2208Includes accessory bar.
Cup Holder ................................................................... $17Part: ACCASMB2634Only available with Two Post Arms.
Accessory Bar for Q4 Seat .............................................. $100Part: MEC143975
17. ACCESSORIESOptional.
16. SET LEGREST LENGTHREQUIRED with matching left and right legrest configuration. All efforts will be made to accommodate legrest length selection, but minor changes may need to be made to meet shipping guidelines. Some adjustments may be needed upon receipt of the unit. Non-matching or individual legrest configurations lengths are not set by the manufacturer.
1. Bracket
2. Pads
3. Installation
Swing-away, Rail Mounts, pair (TWBTLTC) ...................................................................................................................... $472.50Part: INDPART2677. HCPCS: E1028
Curved Pads, 3”x5”, pair (TWBL-3X5) ................................ $210Part: INDPART2663. HCPCS: E0956
Curved Pads, 4”x6”, pair (TWBL-4X6) ................................ $210Part: INDPART2664. HCPCS: E0956
Install LateralsPart: PTOINDV3499
Do Not InstallPart: PTOINDV3500
18.1. Stealth Thoracic LateralsLaterals are not available with the omit back option.
18. POSITIONING COMPONENTSOptional.
Manufacturer installed positioning components section continued on following page.
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Page 7 of 7INFINFB4067/RevC/01OCT2019
Flip Down Bracket (TWBTLADD-HW) ................... $236.25 ea.Part: INDPART2804. HCPCS: E1028
Removable Bracket (LP430) ............................... $262.50 ea.Part: INDPART2805. HCPCS: E1028
Removable Bracket with 1” Offset .......................... $400 ea. (LP430 & LHW-121)
Part: INDPART2854. HCPCS: E1028
Flip Down with LEFT Full Surface Contact ................. $236.25 ea.Feature (TWBADD-L & LPHW407)Part: POS140428. HCPCS: E1028
Flip Down with RIGHT Full Surface Contact ................ $236.25 ea.Feature (TWBADD-R & LPHW407)Part: POS140429. HCPCS: E1028
1. Pelvic/Thigh Guide Bracket
2. Pelvic/Thigh Guide Adapter
18.3. Stealth Pelvic/Thigh GuidesPelvic/thigh guides may interfere with the joystick receiver block and down posts. Please provide quantity next to check box.
2” Height Adapter Plate (LHW-122) .................................$26.25Part: INDPART2821. HCPCS: K0108Height adapter is needed with TRU-Comfort seat cushions. Not avail-able with the flip down bracket.
2 1/4” Adapter Plate (LHW-129) .....................................$53.50Part: POS140430. HCPCS: K0108Only available with the flip down full surface bracket.
3. Pelvic/Thigh Guide Pad^Please verify the appropriate billing code to be used for this item with all third-party payors.
4. Pelvic/Thigh Guide Installation
Short Pad, 4”x4” (TWBADD-4X4) ..............................$75 ea.Part: INDPART2801. HCPCS: E0953^/E0956
Medium Pad, 4”x8” (TWBADD-4X8) ...........................$75 ea.Part: INDPART2802. HCPCS: E0953^/E0956
Long Pad, 4”x12” (TWBADD-4X12) ............................$75 ea.Part: INDPART2803. HCPCS: E0953^/E0956
Install on LeftPart: PTOINDV3585
Install on RightPart: PTOINDV3586
Do Not InstallPart: PTOINDV3719
Account Number: ___________ Date: ________________ Marked for: _____________________________________
1. UniLink Pelvic/Thigh Hardware
2. UniLink Pelvic/Thigh Pads^Please verify the appropriate billing code to be used for this item with all third-party payors.
3. UniLink Pelvic/Thigh Additional Links
18.2. Stealth Unilink Pelvic/Thigh Guide
UniLink, 5" Height Adjustable, ..............$245 ea.Removable Mounting HardwarePart: ST-UTTP5-Q
UniLink, 7" Height Adjustable, ..............$255 ea.Removable Mounting HardwarePart: ST-UTTP7-Q
UniLink, 4" x 4" Pad ..............................$95 ea.Part: ST-UTP544056100-Q
UniLink, 4" x 8" Pad ............................. $105 ea.Part: ST-UTP548056100-Q
UniLink, 4" x 12" Pad ........................... $125 ea.Part: ST-UTP54D056100-Q
UniLink, 1.5" Link ............................... $75 ea.Part: ST-UIL00I150A000-Q
UniLink, 2" Link ................................... $75 ea.Part: ST-UIL00I200A00-Q
UniLink Pad & Hardware
18. POSITIONING COMPONENTS continued
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Quantum® Rehab401 York Ave., Duryea, PA 18642Phone: 866-800-2002 | Fax: 866-707-3422 | Email: [email protected]
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BASECOLOR: OffPI_COMMENTS: Provider Name: Contact: PO Number: Ship to address: Email: City: State: Zip: Phone: Fax: State 2: State 3: State 4: State 5: State 8: State 7: State 9: PI_HEIGHT: PI_WEIGHT: State 6: State 10: BASEMODEL: OffAccount Number: Date: Marked for: base foot: Offne js: Offjs handles 8: Offjs handles 7: Offjs handles 6: Offjs handles 5: Offjs handles 4: Offjs handles 3: Offjs handles 2: Offjs handles 1: Offjs mount: Offjs mount side: OffBatteries 2: Offtransit: OffTB3 SET WIDTH: Offq4seat: OffSTF: Offcane: OffCushion Model Selection: OffAdditional Fluid Proof Liners: OffMatch Seat Width Depth 4: OffCushion Dimensions Width: OffCushion Dimensions Depth: OffSub Cover: OffTB3 Set depth: OffSeat Depth Package: Offcane height: OffARMRESTS L 1: OffARMRESTS L: OffARMRESTS R: OffSET ARMREST HEIGHT: OffRIGHT SET ARMREST HEIGHT: Offoverall back height: Offarm size L: Offarm size R: OffArmpads: Offlap belts: Offhead bracket: Offheadrests: Offback shroud color: Offback cushion: Offpower: OffCM calf support: OffPCMFT EXT: OffPCMFT: Offwidth extension: Off2 bell 6: Off4 outside edge 6: Off6 outside edge 6: OffCM dartex: OffCM FTPT Wheel Bumper 6: OffCM FTPT Connector 6: OffLeg Upper Left: OffLeg Upper Right: OffLeg Upper Pair: OffLower Extension Left: OffRight Lower Extension: OffLower Extension Pair: Offpower toggle: OffLEFT footplate: OffRIGHT Footplate: OffFootplate Pair: OffCheck Box Rim Color 2022: OffCheck Box Rim Color 2021: OffCheck Box Rim Color 2020: OffCheck Box Rim Color 3070: OffCheck Box Rim Color 3062: OffText Field 112: Text Field 113: set_Leg: Offaccessory 2: Offaccessory7: Offacc bar 4: OffThoracic SW rail mnt 19: Offthoracic SA pads: Offthoracic SA install: OffCheck Box Rim Color 3020: OffText Field 108: Check Box Rim Color 3043: OffText Field 107: Check Box Rim Color 3042: OffText Field 106: Check Box Rim Color 3038: OffCheck Box Rim Color 3044: OffCheck Box Rim Color 3046: OffCheck Box Rim Color 3045: OffCheck Box Rim Color 3048: OffText Field 110: Check Box Rim Color 3047: OffCheck Box Rim Color 3024: OffText Field 109: Check Box Rim Color 3051: OffCheck Box Rim Color 3050: OffCheck Box Rim Color 3049: OffText Field 105: Text Field 124: unilink pelvic hardware: OffText Field 123: Text Field 127: unilink pelvic pads: OffText Field 126: Text Field 125: unilink pelvic link: OffText Field 129: unilink pelvic link2: OffText Field 128: