Washington State Medicaid Order Forms

(Dated Prior to 1-5-15)

J6 Series SP (WA Only)

J6 Series Standard (WA Only)

Jazzy 1107 XL Plus Group 2 (WA Only)

Jazzy 1107 XL Plus Group 3 (WA Only)

Jazzy 1420 Series Group 2 (WA Only)

Jazzy 1420 Series Group 3 (WA Only)

Jazzy 1450 SP (WA Only)

Jazzy 1450 Standard (WA Only)

Jazzy 1650 Series (WA Only)

Jazzy 600 ES Series Group 2 (WA Only)

Jazzy 600 ES Series Group 2 Quick Ship (WA Only)

Jazzy 600 Series Group 2 (WA Only)

Jazzy 600 Series Group 3 (WA Only)

Jazzy 614 (WA Only)

Jazzy 614 HD (WA Only)

Jazzy Elite ES Portable (WA Only)

Jazzy Select 14 (WA Only)

Jazzy Select Elite (WA Only)

Jazzy Select HD (WA Only)

Jazzy Select Traveller (WA Only)

Q6 Edge 2.0 with Static Contour Seating (WA Only)

Q6 Edge 2.0 with Static Synergy Seating (WA Only)

Q6 Edge 2.0 with TB3 Power Positioning (WA Only)

Q6 Edge 2.0 with TB3 Static Seating (WA Only)

Q6 Edge HD Standard (WA Only)

Q6 Edge HD TB2 SP MP (WA Only)

Q6 Edge HD TB3 SP MP (WA Only)

Q6 Edge Pediatric TB3 SP MP (WA Only)

Q6 Edge TB2 Power Positioning (WA Only)

Q6 Edge TB3 Power Positioning (WA Only)

Q6 Edge TB3 Static Seating (WA Only)

Q6 Edge with Static Contoured Seating (WA Only)

Q6 Edge with Static Synergy Seating (WA Only)

Quantum 1420 SP/MP (WA Only)

Quantum 1420 Standard (WA Only)

Quantum 1450 SP (WA Only)

Quantum 1450 SP MP (WA Only)

Quantum 1450 Standard (WA Only)

Quantum 1650 Series (WA Only)

Quantum 600 SP/MP (WA Only)

Quantum 600 Standard (WA Only)

Quantum 6000Z HD SP/MP (WA Only)

Quantum 6000Z HD Standard (WA Only)

Quantum 6000Z SP/MP (WA Only)

Quantum 6000Z Standard (WA Only)

Quantum 610 SP (WA Only)

Quantum 610 Standard (WA Only)

Quantum R-4000 SP/MP (WA Only)

Quantum R-4000 Standard (WA Only)

Quantum Rival Standard (WA Only)

Quantum Rival TB2 SP MP (WA Only)

Quantum Rival TB3 SP MP (WA Only)

Z-Chair (WA Only)

Positioning Components (WA Only)

Solid Seat Insert (WA Only)

Specialty Seat Kit (WA Only)

Synergy Seating System (WA Only)

Synergy Shape Back | All Inclusive (WA Only)

Synergy Simplicity Cushion (WA Only)

Synergy Solution 1 Cushion (WA Only)

Synergy Solution Cushion (WA Only)

Synergy Spectrum Air Cushion (WA Only)

Synergy Spectrum Cushion (WA Only)

Syngergy Spectrum Air Contour Cushion (WA Only)

Tru-Balance 2 (WA Only)

Tru-Balance HD Power Tilt (WA Only)

Tru-Balance Pediatric Power Tilt (WA Only)

Tru-Comfort 2 Back Cushion (WA Only)

Tru-Comfort 2 Seat Cushion (WA Only)

Q-Logic Controls (WA Only)

LiteStream Junior (WA Only)

Litestream XF (WA Only)

Stylus LS (WA Only)

Go-Go Elite Traveller Series (WA Only)

Outlander Exterior Lift Series (WA Only)