Stealth Spectrum Gel SPP Cushion Order Form · PDF file 4. Substitute Cushion Cover The...

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Transcript of Stealth Spectrum Gel SPP Cushion Order Form · PDF file 4. Substitute Cushion Cover The...

  • Page 1 of 2INFINFB4042/RevA/15JAN2019

    4. Substitute Cushion Cover The Spectrum Gel SPP cushion is standard with a Coolcore cover (SPCGSPP-NBLKXXYY). The standard Coolcore cover may be substituted with a Tek 2 or Mesh Cover.

    Substitute with Tek 2 Cover Part: SPCGSSP-TBLKXXYY

    Substitute with Mesh Cover Part: SPCGSPP-MBLKXXYY

    1. Cushion Selection

    3. Add Solid Base 22" width and greater cushions include a flat rigidizer standard.

    5. Notes

    401 York Ave., Duryea, PA 18642 | Phone: 866-800-2002 | Fax: 866-707-3422 | Email: quantumorders@pridemobility.com Stealth Spectrum Gel SPP Cushion Order Form

    Cushion Depth: ______

    Cushion Width: ______

    Cushion Part: ST-SPCGSPPXXYY

    Spectrum Gel SPP Cushion, 14"-20" Wide, E2607 .................. $460 Spectrum Gel SPP Cushion, 22"-24" Wide, E2608.................. $530

    Spectrum Gel SPP Cushion This cushion offers skin protection and positioning with a Coolcore, 4-way stretch, breathable cover. Includes urethane liner. Weight capacities are 175 lbs for 14" width, 350 lbs for 16"-20" width, and 550 lbs for 22" width and greater. The XXYY portion of all part numbers on this page directly relate to the dimensions of the cushion, where XX represents the width and YY represents the depth. For example, a 16" wide and 18" deep cushion would be ST-SPCGSPP1618. Available sizes are shown on the chart to the right. Part numbers and prices for options with less predictible part numbers or prices can be found on the parts list attachment. Multiple cushion orders can be configured on the second page.

    This form is interactive when viewed with Adobe Acrobat Reader and may not func- tion correctly if opened with applications other than Acrobat. 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.

    Account Number: ___________ Date: ________________

    Provider Name: __________________________________

    Contact: ________________________________________

    Phone: ___________________ Fax: _________________

    Email: __________________________________________

    PO Number: _____________________________________

    Marked for: _____________________________________

    Ship to Address: _________________________________

    City: _____________________ State: ______ Zip: ______

    _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

    2. Substitute Fluid Proof Liners The Spectrum cushion is standard with an urethane liner but can be substituted with selection below. See parts list attachment for specific prices.

    Fluid Proof Polyurethane Liner .................................... $55-$75 Part: PUL1709030-XXYY

    ABS Flat Rigidizer ..................................................... $45-$65 Part: See parts list attachment.

    ACM Rigidizer ................................................................$95 Part: See parts list attachment. For use with manual wheelchair only.

    14” 16” 17” 18” 19” 20” 22” 24” Width

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  • Page 2 of 2INFINFB4042/RevA/15JAN2019

    _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

    Account Number: ___________ Date: ________________ Marked for: _____________________________________

    ©2018 Quantum Rehab. All rights reserved.

    facebook.com/ QuantumRehab

    youtube.com/ QuantumRehab

    instagram.com/ quantum_rehab

    twitter.com/ quantumrehab

    Special Order Spectrum Gel SPP Cushion Please detail your special order cushion request. All special order cushion requests must be approved with the Quantum Custom Department. Please contact Quantum Inside Sales or Custom Department with questions. Extended lead time will apply. Cushion part numbers involved will be the cushion part number listed in previous sections modified to meet special order request stated in details below. Drawings are available below for sketch details.

    Special Order Spectrum Gel SPP Cushion. E2607/E2608.................................................................................................. $610-$670

    Front View

    Right Side View

    Top View

    Details

    Multiple Order Spectrum Gel SPP Cushion This section allows multiple cushions of various sizes to be ordered. Reference parts, prices, and available sizes on the previous page.

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

  • Page 1 of 2Stealth Spectrum Gel Cushion Parts List: Liners and Rigidizers/15JAN2019

    Stealth Spectrum Gel Cushion Parts List: Liners and Rigidizers

    14"W x 18"D .... URL1709070-1418 .... $50 16"W x 15"D .... URL1709070-1615 .... $50 16"W x 16"D .... URL1709070-1616 .... $50 16"W x 17"D .... URL1709070-1617 .... $50 16"W x 18"D .... URL1709070-1618 .... $50 16"W x 19"D .... URL1709070-1619 .... $50 16"W x 20"D .... URL1709070-1620 .... $50 17"W x 16"D .... URL1709070-1716 .... $50 17"W x 17"D .... URL1709070-1717 .... $50 17"W x 18"D .... URL1709070-1718 .... $50 17"W x 19"D .... URL1709070-1719 .... $50 17"W x 20"D .... URL1709070-1720 .... $50 18"W x 16"D .... URL1709070-1816 .... $50 18"W x 17"D .... URL1709070-1817 .... $50 18"W x 18"D .... URL1709070-1818 .... $50 18"W x 19"D .... URL1709070-1819 .... $50

    18"W x 20"D .... URL1709070-1820 .... $50 18"W x 21"D .... URL1709070-1821 .... $50 18"W x 22"D .... URL1709070-1822 .... $50 18"W x 24"D .... URL1709070-1824 .... $50 19"W x 16"D .... URL1709070-1916 .... $50 19"W x 17"D .... URL1709070-1917 .... $50 19"W x 18"D .... URL1709070-1918 .... $50 19"W x 19"D .... URL1709070-1919 .... $50 19"W x 20"D .... URL1709070-1920 .... $50 20"W x 16"D .... URL1709070-2016 .... $50 20"W x 18"D .... URL1709070-2018 .... $50 20"W x 19"D .... URL1709070-2019 .... $50 20"W x 20"D ....URL1709070-2020 .... $50 20"W x 21"D .... URL1709070-2021 .... $50 20"W x 22"D ....URL1709070-2022 .... $60 20"W x 24"D ....URL1709070-2024 .... $60

    22"W x 16"D .... URL1709070-2216 .... $60 22"W x 18"D .... URL1709070-2218 .... $60 22"W x 19"D .... URL1709070-2219 .... $60 22"W x 20"D ....URL1709070-2220 .... $60 22"W x 22"D ....URL1709070-2222 .... $60 22"W x 24"D ....URL1709070-2224 .... $60 24"W x 16"D .... URL1709070-2416 .... $60 24"W x 18"D .... URL1709070-2418 .... $60 24"W x 19"D .... URL1709070-2419 .... $60 24"W x 20"D .... URL1709070-2420 .... $60 24"W x 21"D .... URL1709070-2421 .... $60 24"W x 22"D .... URL1709070-2422 .... $60 24"W x 24"D .... URL1709070-2424 .... $60 24"W x 26"D .... URL1709070-2426 .... $60

    14"W x 18"D .... PUL1709030-1418 .... $55 16"W x 16"D .... PUL1709030-1616 .... $55 16"W x 18"D .... PUL1709030-1618 .... $55 16"W x 19"D .... PUL1709030-1619 .... $55 16"W x 20"D .... PUL1709030-1620 .... $55 17"W x 16"D .... PUL1709030-1716 .... $55 17"W x 17"D .... PUL1709030-1717 .... $55 17"W x 18"D .... PUL1709030-1718 .... $55 17"W x 19"D .... PUL1709030-1719 .... $55 17"W x 20"D .... PUL1709030-1720 .... $55 18"W x 16"D .... PUL1709030-1816 .... $55 18"W x 17"D .... PUL1709030-1817 .... $55 18"W x 18"D .... PUL1709030-1818 .... $55 18"W x 20"D .... PUL1709030-1820 .... $55

    18"W x 22"D .... PUL1709030-1822 .... $55 18"W x 24"D .... PUL1709030-1824 .... $55 19"W x 16"D .... PUL1709030-1916 .... $55 19"W x 17"D .... PUL1709030-1917 .... $55 19"W x 18"D .... PUL1709030-1918 .... $55 19"W x 19"D .... PUL1709030-1919 .... $55 19"W x 20"D .... PUL1709030-1920 .... $55 20"W x 16"D .... PUL1709030-2016 .... $55 20"W x 18"D .... PUL1709030-2018 .... $55 20"W x 19"D .... PUL1709030-2019 .... $55 20"W x 20"D .... PUL1709030-2020 .... $55 20"W x 21"D .... PUL1709030-2021 .... $55 20"W x 22"D .... PUL1709030-2022 .... $65 20"W x 24"D .... PUL1709030-2024 .... $65

    22"W x 16"D .... PUL1709030-2216 .... $65 22"W x 18"D .... PUL1709030-2218 .... $65 22"W x 19"D .... PUL1709030-2219 .... $65 22"W x 20"D .... PUL1709030-2220 .... $65 22"W x 22"D .... PUL1709030-2222 .... $65 22"W x 24"D .... PUL1709030-2224 .... $65 24"W x 16"D .... PUL1709030-2416 .... $65 24"W x 18"D .... PUL1709030-2418 .... $65 24"W x 19"D .... PUL1709030-2419 .... $65 24"W x 20"D .... PUL1709030-2420 .... $65 24"W x 21"D .... PUL1709030-2421 .... $65 24"W x 22"D .... PUL1709030-2422 .... $65 24"W x 24"D .... PUL1709030-2424 .... $65 24"W x 26"D .... PUL1709030-2426 .... $65

    Cushion Size Part MSRP Cushion Size Part MSRP Cushion Size Part MSRP URETHANE CUSHION LINERS

    Cushion Size Part MSRP Cushion Size Part MSRP Cushion Size Part MSRP POL