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Quantum REF: COM/0103-1
Rev.: B Effective Date: 8/8/16
Approved by: Julie Piriano

Quantum Rehab Provider Standards - Policy Exception & Attestation Form
Effective August 1, 2016

These guidelines have been established to protect Pride Mobility Products Corporation's reputation as the company that delivers the industry's premium brand of products. This document was developed to ensure that entities providing Quantum Rehab products (a division of Pride Mobility Products Corporation) understand and adhere to set standards for the benefit of all Complex Rehab providers and consumers.

In order for any entity to be considered as an authorized provider of Pride Mobility Products Corporation (“Pride/Quantum”) it must fully comply with all of the following criteria:

  • The provider must maintain a commercial business location consistent with the needs of their business activities and customers.
  • The provider must establish an account with Pride, which includes a minimum credit limit, minimum initial purchase and minimum annual purchases so that prompt delivery and service to consumers may be assumed.
  • With respect to each interaction with a consumer purchasing a Pride product, the provider must assume responsibility for careful product selection, fitting, delivery, set-up and instruction. This includes, but is not limited to, providing the consumer (as well as the caregiver, where appropriate) with clear instructions relating to the safe use and potential hazards of products and accessories as well as information regarding product care and maintenance. In addition, the provider must properly deliver all Pride product and/or accessory manuals, instructions and warnings. The provider's goal in each consumer interaction must be to assure a safe, reliable experience for the consumer when utilizing a Pride product or accessory.
  • The provider must regularly review the Pride provider website and otherwise maintain a current working knowledge of all Pride product technologies.
  • The provider assumes all responsibility for repair services for all Pride products and accessories sold, and the provider must maintain sufficient resources to provide such repair services (i.e., service what you provide).
  • The provider's advertising must clearly identify it as an authorized Pride provider and in no way portray or imply that they are the manufacturer of a Pride product or accessory.
  • Only authorized providers may advertise Pride products online for the purpose of education.
  • It is each provider's responsibility to ensure that all requirements for third-party payers are met, when applicable, for the resale of all Pride products.
  • The provider and all individuals employed by the provider must remain committed to compliance with all applicable federal and state laws governing the sale and delivery of Pride products, including, without limitation, Medicare and Medicaid compliance and in particular, but not limited to, Medicare-published DMEPOS Supplier Standards as they may be amended from time to time. The provider must not be excluded from a federal or state healthcare program.

For the purposes of this policy Quantum Rehab Products are considered to be Group 2 PWCs with single power options and above (K0835 – K0886), all power positioning systems and alternate drive devices.

Quantum Rehab will authorize a provider to purchase and resell Quantum Rehab Products if all of the following criteria are met, the provider is in compliance with the Pride authorized provider standards and the provider remains in compliance with the following:

  1. Quantum Rehab products many NOT be sold over the Internet. Use of the Internet is to be for educational purposes only.
  2. Quantum Rehab products will be provided by a RESNA certified Assistive Technology Professional (ATP) specializing in wheelchairs who is a W2 employee of the provider and who is directly involved in the wheelchair selection with the consumer.
  3. Quantum Rehab providers will employ at least one trained rehab technician per service area and either service the Quantum Rehab products they sell, or assist the consumer in finding a qualified Quantum Rehab provider to service their product in the event the consumer does not reside in the provider's established service area.

This policy exception and attestation form shall be completed by any provider who does not meet both criterion 2 and 3 above and is seeking such exception to purchase and resell a Quantum Rehab product. In completing this policy exception the person attesting on behalf of the provider may be relied upon by Quantum and Pride Mobility Products Corporation in its effort to assure compliance with Quantum's Rehab provider policy. This exception must be completed and approved prior to order fulfillment.

Company Name:
Account Number:
Company Address:
Street:
City: State: Zip:
Company Phone:
Company Fax:
Company Contact Email Address:
Are you a Medicare Provider? Yes No

ATP Information:



Name:
Certification ID Number:
Certification Expiration Date:
Location:
Email Address:

Rehab Technician:



Name:

Quantum base requested
Seating/positioning requested
Power positioning requested
Drive control requested

Reason(s) for Exception if No ATP Employed by Provider (check all that apply)





Person's Name Completing this Application:
Date: 9/25/2016

By clicking here I agree to the terms and conditions of this agreement (electronic signature)

This policy exception and attestation form must be approved by Pride's Compliance Department and authorization by Pride/Quantum's rehab review team must be on file prior to order fulfillment.

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