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Page 1 of 1 INFINFB3583/RevB/1MAY2017 Synergy ® Solution ® 1 Cushion Order Form Quantum ® Rehab 401 York Ave., Duryea, PA 18642 Phone: 866-800-2002 | Fax: 866-707-3422 | Email: [email protected] Account Number: ___________ Date: ________________ Provider Name: __________________________________ Contact: ________________________________________ Phone: ___________________ Fax: _________________ Email:__________________________________________ PO Number:_____________________________________ Marked for: _____________________________________ Ship to Address: _________________________________ City: _____________________ State: ______ Zip: ______ SOLUTION 1 CUSHION Weight Capactity is 350 lbs. All Synergy cushions have a 2 year, limited warranty. CUSTOM SOLUTION 1 CUSHION Please detail your custom cushion request below. All custom cushion request must be approved with the Quantum Custom Department. Please contact Quantum Inside Sales or Custom Department with questions. 14"W x 16"D CUSASMB1802 E2603 $430 16"W x 16"D CUSASMB1804 E2603 $430 16"W x 18"D CUSASMB1805 E2603 $430 16"W x 20"D CUSASMB1806 E2603 $430 17"W x 17"D CUSASMB1807 E2603 $430 17"W x 19"D CUSASMB1808 E2603 $430 18"W x 16"D CUSASMB1809 E2603 $430 18"W x 18"D CUSASMB1810 E2603 $430 18"W x 20"D CUSASMB1811 E2603 $430 18"W x 22"D CUSASMB1812 E2603 $430 19"W x 17"D CUSASMB1814 E2603 $430 19"W x 19"D CUSASMB1815 E2603 $430 20"W x 16"D CUSASMB1816 E2603 $430 20"W x 18"D CUSASMB1817 E2603 $430 20"W x 20"D CUSASMB1818 E2603 $430 20"W x 22"D CUSASMB1819 E2603 $430 22"W x 16"D CUSASMB1821 E2604 $480 22"W x 18"D CUSASMB1822 E2604 $480 22"W x 20"D CUSASMB1823 E2604 $480 22"W x 22"D CUSASMB1824 E2604 $480 22"W x 24"D CUSASMB1825 E2604 $480 24"W x 18"D CUSASMB1827 E2604 $480 24"W x 20"D CUSASMB1828 E2604 $480 24"W x 22"D CUSASMB1829 E2604 $480 24"W x 24"D CUSASMB1830 E2604 $480 Custom Size CUSCUST1002 E2603/E2604 $530 Qty Size Part HCPCS Code MSRP Qty Size Part HCPCS Code MSRP ©2016 Quantum Rehab - A Pride Mobility Products Corporation company. All rights reserved. HCPCS codes provided should not be considered as legal advice and do not guarantee reimbursement. DME providers are responsible for determin- ing appropriate billing codes when submitting for insurance reimbursement. All prices are MSRP. Prices, specifications, part numbers, and availability are subject to change without notice. Top View Front View Side View
