Page 1 of 2INFINFB4045/RevB/03JUN2019

1. Cushion Selection

2. Add Solid BaseABS Flat Rigidizer ..................................................... $45-$65Part: See parts list attachment.

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

3. Notes

401 York Ave., Duryea, PA 18642 | Phone: 866-800-2002 | Fax: 866-707-3422 | Email: quantumorders@pridemobility.comStealth Simplicity G Cushion Order Form

Cushion Depth: ______

Cushion Width: ______

Cushion Part: ST-SIMGXXYY

Simplicity G Cushion, 10"-20" Wide, E2601 ..........................$110Simplicity G Cushion, 22"-24" Wide, E2602 ..........................$165

Simplicity G CushionThis is a general use cushion with a Stealth Tek 2, 2-way stretch, breathable cover. Weight capacities are 150 lbs for 10"-14" width, 350 lbs for 15"-21" width, and 400 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-SIMG1618. 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: ______

_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

Width

Dept

h

Multiple Order Simplicity G CushionThis section allows multiple cushions of various sizes to be ordered. Reference parts, prices, and available sizes above.

Quant

ity

Width

Depth

ABS ACM

Tek 2

A

B

C

D

E

F

Rigid

izer

Cove

rSiz

e

Page 2 of 2INFINFB4045/RevB/03JUN2019

_____________________________________________________________________________________ _____________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Account Number: ___________ Date: ________________ Marked for: _____________________________________

©2019 Quantum Rehab.All rights reserved.

facebook.com/QuantumRehab

youtube.com/QuantumRehab

instagram.com/quantum_rehab

twitter.com/quantumrehab

Special Order Simplicity G 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 Simplicity G Cushion. E2601/E2602 ......................................................................................................... $210-$265

Front View

Right Side View

Top View

Details

Page 1 of 1Stealth Simplicity Cushion Parts List: Rigidizers/29MAY2019

PREL

IMIN

ARY

Stealth Simplicity Cushion Parts List: Rigidizers

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. ©2019 Quantum Rehab - A Pride Mobility Products Corporation company. All rights reserved..

Cushion Size Part MSRP Cushion Size Part MSRP Cushion Size Part MSRP10"W x 10"D ......DWR1010E188A ..... $4510"W x 12"D ......DWR1010E188C ..... $4510"W x 14"D ......DWR1010E188E...... $4512"W x 10"D ......DWR1010E189A...... $4512"W x 12"D ......DWR1010E189C ..... $4512"W x 14"D ......DWR1010E189E ...... $4514"W x 10"D .... MEC1804152-1410 .... $4514"W x 12"D ......DWR1010E190C ..... $4514"W x 14"D ......DWR1010E190E...... $4514"W x 16"D ......DWR1010E190G ..... $4515"W x 15"D .... MEC1804152-1515 .... $4515"W x 16"D .... MEC1804152-1515 .... $4515"W x 17"D ..... DWR1010E232H ..... $45

16"W x 16"D ......DWR1010E191G...... $4516"W x 18"D ...... DWR1010E191I ...... $45

16"W x 20"D ......DWR1010E191K ...... $4517"W x 17"D ..... DWR1010E234H ..... $4517"W x 18"D ..... DWR1010E234H ..... $4517"W x 19"D ......DWR1010E234J ..... $4517"W x 20"D ..... DWR1010E234H ..... $4518"W x 16"D ......DWR1010E192G ..... $4518"W x 18"D ...... DWR1010E192I ...... $4518"W x 20"D ......DWR1010E192K ..... $4518"W x 22"D ..... DWR1010E192M ..... $4519"W x 17"D .... MEC1804152-1917 .... $4519"W x 18"D .... MEC1804152-1917 .... $4519"W x 19"D .... MEC1804152-1919 .... $4519"W x 20"D .... MEC1804152-1919 .... $45

20"W x 16"D ......DWR1010E193G ..... $5520"W x 18"D ...... DWR1010E193I ...... $55

20"W x 20"D ......DWR1010E193K...... $5520"W x 22"D ......DWR1010E193M ..... $5522"W x 16"D ......DWR1010E193G ..... $5522"W x 18"D ...... DWR1010E193I ...... $5522"W x 20"D ......DWR1010E193K...... $5522"W x 22"D ......DWR1010E193M ..... $5522"W x 24"D ......DWR1010E193O ..... $5524"W x 18"D ...... DWR1010E236I ...... $5524"W x 19"D ...... DWR1010E236I ...... $5524"W x 20"D ......DWR1010E236K ..... $5524"W x 21"D ......DWR1010E236K ..... $5524"W x 22"D ..... DWR1010E236M ..... $5524"W x 23"D ..... DWR1010E236M ..... $55

24"W x 24"D ..... DWR1010E236O ..... $55

ABS FLAT RIGIDIZER

16"W x 16"D ..... CUS142467-1616 .... $9516"W x 18"D .........CUS142467 ........ $9516"W x 20"D .........CUS142467 ........ $9517"W x 17"D ..... CUS142466-1816 ..... $9517"W x 18"D ..... CUS142466-1818 ..... $9517"W x 19"D ..... CUS142466-1818 ..... $95

17"W x 20"D ........ CUS142466 ........ $9518"W x 16"D ..... CUS142466-1816 ..... $9518"W x 18"D ..... CUS142466-1818 ..... $9518"W x 20"D ........ CUS142466 ........ $9518"W x 22"D ........ CUS142466 ........ $9519"W x 18"D .....CUS142465-2018 ..... $95

19"W x 19"D .....CUS142465-2018 ..... $9519"W x 20"D .........CUS142465 ........ $9520"W x 18"D .....CUS142465-2018 ..... $9520"W x 20"D .........CUS142465 ........ $9520"W x 22"D .........CUS142465 ........ $95

Cushion Size Part MSRP Cushion Size Part MSRP Cushion Size Part MSRPACM RIGIDIZER