Quantum Rehab Q6 Edge 2.0 X Manual

Quantum
401 York Ave., Duryea, PA 18642
Phone: 866-800-2002 | Fax: 866-707-3422 | Email: quantumorders@pridemobility.com
Q6 Edge
Account Number: ___________ Date: ________________
Provider Name: __________________________________
Contact: ________________________________________
Phone: ___________________ Fax: _________________
Email: __________________________________________
PO Number: _____________________________________
Marked for: _____________________________________
Ship to Address: _________________________________
City: _____________________ State: ______ Zip: ______
INTRODUCTION
This form is interactive when viewed with
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 (quantumorders@pridemobility.com). 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
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
PATIENT INFORMATION
Weight:________ Height:________
1. BASE MODEL
REQUIRED. Select a group 3 power base. This power base has a 300 lb. weight capacity, standard 6 mph programmable motors, 8 amp off board charger, fender
lights, 2 multipliers, and USB mobile device charger. Power positioning includes an attendant control and iAccess interface. Dimensions of base without legrests:
24"W x 35.5"L.
Quantum Q6 Edge 2.0 X 3S-SS ......................................$10,195
Part: Q6EDGE 2.0X 3S-SS. HCPCS: K0848
Solid seat pan standard with no power option.
Quantum Q6 Edge 2.0 X 3SP-SS .....................................$10,195
Part: Q6EDGE 2.0X 3SP-SS. HCPCS: K0856
Single power option.
INFINFB3745/RevF/09DEC2019
Rehab
®
2.0 X Order Form with TRU-Balance
®
Adobe Acrobat Reader
with this order form.
cross-reference spreadsheet
Thank you for choosing Quantum!
A. Shoulder Width: _______
B. Chest Width: _________
C. Hip Width: ___________
____________________________________________________________
____________________________________________________________
____________________________________________________________
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and may not function correctly if opened with applications other than Acrobat.
for the XRef part numbers.
D. Max Sitting Height: ____
E. Shoulder Height: ______
F. Axilla Height: _________
Quantum Q6 Edge 2.0 X 3MP-SS ....................................$10,195
Part: Q6EDGE 2.0X 3MP-SS. HCPCS: K0861
Multiple actuator power option.
3 Positioning
®
G. Thigh Depth: _________
H. Lower Leg Length: ____
I. Elbow Height: ________
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