Stealth Spectrum Gel SPP Cushion Order Form · 4. Substitute Cushion Cover The Spectrum Gel SPP...
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Page 1 of 2 INFINFB4042/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: [email protected] 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 Depth
Transcript of Stealth Spectrum Gel SPP Cushion Order Form · 4. Substitute Cushion Cover The Spectrum Gel SPP...
Page 1 of 2INFINFB4042/RevA/15JAN2019
4. Substitute Cushion CoverThe 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 CoverPart: SPCGSSP-TBLKXXYY
Substitute with Mesh CoverPart: SPCGSPP-MBLKXXYY
1. Cushion Selection
3. Add Solid Base22" 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: [email protected] Spectrum Gel SPP Cushion Order Form
Cushion Depth: ______
Cushion Width: ______
Cushion Part: ST-SPCGSPPXXYY
Spectrum Gel SPP Cushion, 14"-20" Wide, E2607 .................. $460Spectrum Gel SPP Cushion, 22"-24" Wide, E2608.................. $530
Spectrum Gel SPP CushionThis 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 LinersThe 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-$75Part: PUL1709030-XXYY
ABS Flat Rigidizer ..................................................... $45-$65Part: See parts list attachment.
ACM Rigidizer ................................................................$95Part: See parts list attachment.For use with manual wheelchair only.
14” 16” 17” 18” 19” 20” 22” 24”Width
Dept
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_____________________________________________________________________________________ _____________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Account Number: ___________ Date: ________________ Marked for: _____________________________________
©2018 Quantum Rehab.All rights reserved.
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Special Order Spectrum Gel SPP CushionPlease 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 CushionThis section allows multiple cushions of various sizes to be ordered. Reference parts, prices, and available sizes on the previous page.
Quant
ity
Width
Depth
Ureth
ane
Polyu
r.ABS AC
M
Coolc
ore
Tek 2
Mesh
A
B
C
D
E
F
Liner
Rigid
izer
Cove
rSiz
e
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 .... $5016"W x 15"D .... URL1709070-1615 .... $5016"W x 16"D .... URL1709070-1616 .... $5016"W x 17"D .... URL1709070-1617 .... $5016"W x 18"D .... URL1709070-1618 .... $5016"W x 19"D .... URL1709070-1619 .... $5016"W x 20"D .... URL1709070-1620 .... $5017"W x 16"D .... URL1709070-1716 .... $5017"W x 17"D .... URL1709070-1717 .... $5017"W x 18"D .... URL1709070-1718 .... $5017"W x 19"D .... URL1709070-1719 .... $5017"W x 20"D .... URL1709070-1720 .... $5018"W x 16"D .... URL1709070-1816 .... $5018"W x 17"D .... URL1709070-1817 .... $5018"W x 18"D .... URL1709070-1818 .... $5018"W x 19"D .... URL1709070-1819 .... $50
18"W x 20"D .... URL1709070-1820 .... $5018"W x 21"D .... URL1709070-1821 .... $5018"W x 22"D .... URL1709070-1822 .... $5018"W x 24"D .... URL1709070-1824 .... $5019"W x 16"D .... URL1709070-1916 .... $5019"W x 17"D .... URL1709070-1917 .... $5019"W x 18"D .... URL1709070-1918 .... $5019"W x 19"D .... URL1709070-1919 .... $5019"W x 20"D .... URL1709070-1920 .... $5020"W x 16"D .... URL1709070-2016 .... $5020"W x 18"D .... URL1709070-2018 .... $5020"W x 19"D .... URL1709070-2019 .... $5020"W x 20"D ....URL1709070-2020 .... $5020"W x 21"D .... URL1709070-2021 .... $5020"W x 22"D ....URL1709070-2022 .... $6020"W x 24"D ....URL1709070-2024 .... $60
22"W x 16"D .... URL1709070-2216 .... $6022"W x 18"D .... URL1709070-2218 .... $6022"W x 19"D .... URL1709070-2219 .... $6022"W x 20"D ....URL1709070-2220 .... $6022"W x 22"D ....URL1709070-2222 .... $6022"W x 24"D ....URL1709070-2224 .... $6024"W x 16"D .... URL1709070-2416 .... $6024"W x 18"D .... URL1709070-2418 .... $6024"W x 19"D .... URL1709070-2419 .... $6024"W x 20"D .... URL1709070-2420 .... $6024"W x 21"D .... URL1709070-2421 .... $6024"W x 22"D .... URL1709070-2422 .... $6024"W x 24"D .... URL1709070-2424 .... $6024"W x 26"D .... URL1709070-2426 .... $60
14"W x 18"D .... PUL1709030-1418 .... $5516"W x 16"D .... PUL1709030-1616 .... $5516"W x 18"D .... PUL1709030-1618 .... $5516"W x 19"D .... PUL1709030-1619 .... $5516"W x 20"D .... PUL1709030-1620 .... $5517"W x 16"D .... PUL1709030-1716 .... $5517"W x 17"D .... PUL1709030-1717 .... $5517"W x 18"D .... PUL1709030-1718 .... $5517"W x 19"D .... PUL1709030-1719 .... $5517"W x 20"D .... PUL1709030-1720 .... $5518"W x 16"D .... PUL1709030-1816 .... $5518"W x 17"D .... PUL1709030-1817 .... $5518"W x 18"D .... PUL1709030-1818 .... $5518"W x 20"D .... PUL1709030-1820 .... $55
18"W x 22"D .... PUL1709030-1822 .... $5518"W x 24"D .... PUL1709030-1824 .... $5519"W x 16"D .... PUL1709030-1916 .... $5519"W x 17"D .... PUL1709030-1917 .... $5519"W x 18"D .... PUL1709030-1918 .... $5519"W x 19"D .... PUL1709030-1919 .... $5519"W x 20"D .... PUL1709030-1920 .... $5520"W x 16"D .... PUL1709030-2016 .... $5520"W x 18"D .... PUL1709030-2018 .... $5520"W x 19"D .... PUL1709030-2019 .... $5520"W x 20"D .... PUL1709030-2020 .... $5520"W x 21"D .... PUL1709030-2021 .... $5520"W x 22"D .... PUL1709030-2022 .... $6520"W x 24"D .... PUL1709030-2024 .... $65
22"W x 16"D .... PUL1709030-2216 .... $6522"W x 18"D .... PUL1709030-2218 .... $6522"W x 19"D .... PUL1709030-2219 .... $6522"W x 20"D .... PUL1709030-2220 .... $6522"W x 22"D .... PUL1709030-2222 .... $6522"W x 24"D .... PUL1709030-2224 .... $6524"W x 16"D .... PUL1709030-2416 .... $6524"W x 18"D .... PUL1709030-2418 .... $6524"W x 19"D .... PUL1709030-2419 .... $6524"W x 20"D .... PUL1709030-2420 .... $6524"W x 21"D .... PUL1709030-2421 .... $6524"W x 22"D .... PUL1709030-2422 .... $6524"W x 24"D .... PUL1709030-2424 .... $6524"W x 26"D .... PUL1709030-2426 .... $65
Cushion Size Part MSRP Cushion Size Part MSRP Cushion Size Part MSRPURETHANE CUSHION LINERS
Cushion Size Part MSRP Cushion Size Part MSRP Cushion Size Part MSRPPOLYURETHANE CUSHION LINERS
Account Number: ___________ Date: ________________ Marked for: _____________________________________
Cushion Size Part MSRP Cushion Size Part MSRP Cushion Size Part MSRP14"W x 18"D ...... DWR1010E189I ...... $4516"W x 16"D ......DWR1010E190G ..... $4516"W x 18"D ...... DWR1010E190I ...... $4516"W x 20"D ......DWR1010E190K ..... $4517"W x 17"D ..... DWR1010E232H ..... $4517"W x 19"D ......DWR1010E232J ..... $4518"W x 16"D ......DWR1010E191G...... $4518"W x 18"D ...... DWR1010E191I ...... $4518"W x 20"D ......DWR1010E191K ...... $4518"W x 22"D ......DWR1010E191M ..... $45
18"W x 24"D ......DWR1010E191O ..... $4519"W x 17"D ..... DWR1010E234H ..... $4519"W x 19"D ......DWR1010E234J ..... $4520"W x 16"D ......DWR1010E192G ..... $5520"W x 18"D ...... DWR1010E192I ...... $5520"W x 20"D ......DWR1010E192K ..... $5520"W x 22"D ..... DWR1010E192M ..... $5520"W x 24"D ......DWR1010E192O ..... $5522"W x 16"D ......DWR1010E193G ..... $5522"W x 18"D ...... DWR1010E193I ...... $55
22"W x 20"D ......DWR1010E193K...... $5522"W x 22"D ......DWR1010E193M ..... $5522"W x 24"D ......DWR1010E193O ..... $5524"W x 16"D ......DWR1010E194G ..... $5524"W x 18"D ...... DWR1010E194I ...... $5524"W x 20"D ......DWR1010E194K ..... $5524"W x 22"D ..... DWR1010E194M ..... $5524"W x 24"D ......DWR1010E194O ..... $55
ABS FLAT RIGIDIZER
Page 2 of 2Stealth Spectrum Gel Cushion Parts List: Liners and Rigidizers/15JAN2019
Account Number: ___________ Date: ________________ Marked for: _____________________________________
This form is interactive when viewed with Adobe Acrobat Reader and may not function 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. ©2018 Quantum Rehab - A Pride Mobility Products Corporation company. All rights reserved.
16"W x 16"D .........CUS142467 ........ $9516"W x 17"D .........CUS142467 ........ $9516"W x 18"D .........CUS142467 ........ $9518"W x 16"D ........ CUS142466 ........ $95
18"W x 18"D ........ CUS142466 ........ $9518"W x 19"D ........ CUS142466 ........ $9518"W x 20"D ........ CUS142466 ........ $9520"W x 18"D .........CUS142465 ........ $95
20"W x 19"D .........CUS142465 ........ $9520"W x 20"D .........CUS142465 ........ $95
Cushion Size Part MSRP Cushion Size Part MSRP Cushion Size Part MSRPACM RIGIDIZER
