Quantum Q6 Edge 3 Order Form with TRU Balance 3 Positioning
This file provides the order form for Quantum Q6 Edge 3 with TRU Balance 3 Positioning. It contains detailed instructions and options to customize the power chair according to patient needs. The form includes sections for base models, drive motors, base colors, lights, backup cameras, and more.
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How do I fill this out?
To fill out this form, you need Adobe Acrobat Reader for the interactive fields. Choose the options by checking the relevant boxes and provide required information in the interactive fields. You can print or submit the form via email using the buttons at the bottom of the form.
How to fill out the Quantum Q6 Edge 3 Order Form with TRU Balance 3 Positioning?
1
Open the form using Adobe Acrobat Reader.
2
Check the boxes for desired options and fill in the interactive fields.
3
Print or submit the form via email using the buttons at the bottom of the form.
4
Save the form if you need to email it via a web-based application.
5
Contact Quantum Sales for assistance if needed.
Who needs the Quantum Q6 Edge 3 Order Form with TRU Balance 3 Positioning?
1
Medical Professionals need this form to order customized power chairs for patients.
2
Patients who require specific positioning in their power chairs need this form.
3
DME Providers need this form to determine the appropriate billing codes when submitting for insurance reimbursement.
4
Rehabilitation Centers need this form to order power chairs with specific configurations.
5
Home Care Providers require this form to ensure the right fit and functionality of the power chair for their clients.
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What are the instructions for submitting this form?
To submit this form, complete all required fields and select the appropriate options. Fax the completed form to 866-707-3422 or email it to quantumorders@pridemobility.com. For online submissions, 'Save As' the completed PDF and attach it to your email. Ensure all required sections are filled out to avoid delays in ordering. For assistance with the form, contact Quantum Sales at 866-800-2002.
What are the important dates for this form in 2024 and 2025?
This form is valid through June 2024. Ensure all orders comply with the form's latest revision: INFINFB4225/RevN/JUN2024.
What is the purpose of this form?
The purpose of this form is to streamline the customization and ordering process for Quantum Q6 Edge 3 power chairs. It allows healthcare providers and patients to select from a variety of options and configurations to meet specific mobility needs. The form ensures accurate order placement and efficient processing for timely delivery of the customized power chair.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Information: Sections for weight, height, and various body measurements to customize the chair.
- 2. Base Model: Options for selecting the base model, including part numbers and prices.
- 3. Drive Motors: Choices for various motor options, with specifications and pricing.
- 4. Base Color: Options for selecting the shroud color, both standard and hydrographic.
- 5. Base Mounted Lights: Choices for different lighting options, including fender and full light packages.
- 6. Quantum Backup Camera: Optional camera with various mounting bracket options.
- 7. Drive Wheels: Selections for drive wheel types, tires, and accent colors.
- 8. Batteries: Options for different battery types and their pricing.
- 9. Patient's Weight: Required field for specifying patient's weight to customize the chair.
- 10. Extended Seat Towers: Optional extended seat towers for specific seat types.
- 11. Electronics: Selection of drive control types, joysticks, and expandable control systems.
What happens if I fail to submit this form?
Failing to submit the order form may delay the quote or order processing.
- Incomplete Orders: Customer service will contact you to resolve any issues.
- Delayed Delivery: Incomplete forms may result in delays in receiving the customized power chair.
- Compatibility Issues: Any compatibility issues will be addressed by customer service to ensure proper order placement.
How do I know when to use this form?
- 1. Healthcare Providers: To order customized power chairs for patients.
- 2. Patients: To specify their requirements for a customized power chair.
- 3. Rehabilitation Centers: To ensure the right fit and functionality of the power chair for their clients.
- 4. Home Care Providers: To meet the needs of clients requiring specialized mobility solutions.
- 5. DME Providers: To determine the appropriate billing codes for insurance reimbursement.
Frequently Asked Question
How do I fill out this order form?
Use Adobe Acrobat Reader to select options and input required information. Then print or submit the form using the provided buttons.
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Use PrintFriendly's PDF editor to add your electronic signature.
Can I share the PDF from PrintFriendly?
Yes, you can share the PDF via email, a shareable link, or upload it to cloud storage services.
What if I need assistance filling out the form?
Contact Quantum Sales at 866-800-2002 for help with the form.
How do I submit the completed form?
You can fax it to 866-707-3422 or email it to quantumorders@pridemobility.com.
Are there specific codes for insurance reimbursement?
HCPCS codes are provided, but DME providers should determine the appropriate codes for billing.
What if the form is incomplete?
Customer service will contact you if there are any issues with the submitted form.
Can I print the form after filling it out?
Yes, you can print the form using the Print button at the bottom.
What software is required to view the interactive fields?
Adobe Acrobat Reader is required to properly view and interact with the form fields.
