j4 order form with power positioning seating...part: ptoindv3882. hcpcs: e1002 55° center of...

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


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



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



http://wc-transportation-safety.umtri.umich.edu/crash-tested-product-lists/wheelchairshttp://wc-transportation-safety.umtri.umich.edu/crash-tested-product-lists/wheelchairs


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




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






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


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


17” HeightPart: SETHGHT1030





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



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




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



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.


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


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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©2019 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]

https://www.facebook.com/QuantumRehabhttps://www.youtube.com/user/QuantumRehabhttps://www.instagram.com/quantum_rehab/https://twitter.com/quantumrehab

Button 37: Page 1: Page 2: Page 3: Page 4: Page 5: Page 6: Page 7:

aButton 47: Page 1: Page 2: Page 3: Page 4: Page 5: Page 6: Page 7:

Print Form 4: Page 1: Page 2: Page 3: Page 4: Page 5: Page 6: Page 7:

SubmitViaEmail 4: Page 1: Page 2: Page 3: Page 4: Page 5: Page 6: Page 7:

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:

j4 order form with power positioning seating...part: ptoindv3882. hcpcs: e1002 55° center of...

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