Quantum Rehab Provider Standards Attestation Form

Quantum REF: COM/0102-1
Rev.: D Effective Date: 12/21/17
Approved by: Julie Piriano

Please read the following standards and complete the form below.
Provide current company contact information.

Quantum Rehab Provider Standards
Effective January 1, 2018

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.
  • No advertising may make claims beyond Pride’s standard written specifications, warranties, instructions, policies and procedures.
  • Any product advertised below Pride’s Minimum Advertised Price (MAP) in any and all media violates the MAP policy and is strictly prohibited.
  • 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.

Those applying to purchase and resell Quantum Rehab products after January 1, 2018, including providers located in Puerto Rico, must meet these standards, complete the attestation form below and be approved as an authorized Quantum provider. All Quantum Rehab providers understand that they may be evaluated from time to time to ensure compliance with these standards.

For the purposes of this policy Quantum Rehab Products are considered to be Group 2 PWCs with single power options and above (K0835 - K0886). It is also required for the sale of all power positioning systems and all alternate drive control devices sold at initial issue or as a modification to a consumer owned power wheelchair. This policy does not apply to the sale of parts used in the repair of a consumer owned power wheelchair

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 above 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 process 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.

If standard # 2 or # 3 above is not met Quantum Rehab will only allow the purchase and resale of a Quantum Rehab Product with an approved policy exception on file. A policy exception form can be found at www.prideprovider.com or www.quantumrehab.com.

Quantum Rehab Provider Attestation Form
* Required Fields

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

ATP Information:
(If more than 3, provide additional information on a separate form)

N/A no ATP**
** If you do not have an ATP on staff a policy exception form must be completed and approved prior to order fulfillment. The Policy Exception form can be found at www.prideprovider.com or www.quantumrehab.com.

Certification ID Number*:
Certification Expiration Date*:
*** If the ATP is a 1099 subcontracted entity a policy exception form must be completed and approved prior to order fulfillment.
Email Address:

Certification ID Number:
Certification Expiration Date:
*** If the ATP is a 1099 subcontracted entity a policy exception form must be completed and approved prior to order fulfillment.
Email Address:

Certification ID Number:
Certification Expiration Date:
*** If the ATP is a 1099 subcontracted entity a policy exception form must be completed and approved prior to order fulfillment.
Email Address:

Rehab Technician(s):
(If more than 3, provide additional information on a separate form)


Person's Name Completing this Application:
Date: 11/25/2020

To further ensure compliance with these guidelines, we have implemented a process where violations may be reported to Pride's Compliance Department by completing a Quantum Rehab Provider Violation Notification found at www.pridemobility.com, www.quantumrehab.com or www.prideprovider.com. In addition, a compliant may be submitted by email to compliance@pridemobility.com for further investigation. Please note if you alert us to a violation, you will not receive a response regarding the outcome of our investigation and, if applicable, any action taken against the violator.

Quantum Rehab shall be responsible for the administration, tracking and compliance with this policy. All inquiries regarding the Quantum Rehab Provider Standards must be addressed to Pride's Compliance Department via email: compliance@pridemobility.com.

Quantum Rehab reserves the right to deny or deactivate a provider account for any reason. A provider will be prohibited from purchasing Quantum Rehab products for resale if their account is denied or deactivated. For an electronic copy of these standards please visit www.pridemobility.com, www.quantumrehab.com or www.prideprovider.com.

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