Quickie QXi January 2019

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1 Quickie QXi SUBMIT January 2019 EIF6 Mark Fr: Submitting fr: Date: PO#: Qute Order Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFORMATION Dealer Cntact: Ship T: Dealer Address: Attentin: Dealer City: Dealer Phne: ( Cnfirmatin Cnfirm Via: ST: Address: ZIP: Fax: ( Address: Ship T City: Fax ST: Ship T Phne: ( ZIP: Fax: ( The HCPCS CODES prvided are based n cde verificatin thrugh PDAC r ur interpretatin f the cde definitins. The use f HCPCS CODES des nt ensure cverage r payment. Fr cverage infrmatin, verify the apprpriate payer's cverage plicy. a Optin # HCPCS Definitin Price Optin # a HCPCS Definitin Price 1. FRAME Base Mdel Weight capacity 265 lbs 196WM78 K0005 Quickie QXi (Adjustable Axle Fr sizes use E1236 $1, Frame Style See Seat Height Matrix n page 2 196FS9 Standard Frame 196FS30 Hemi Frame 196TO38 Transit K0108 Transit System WC19 2. SIZE / SEATING Frame Width 196W5 196W6 196W7 196W8 196W9 196W10 196W11 16" 17" 18" 19" E " $ Seat Depth Frame Depths equals Seat Depths. 196SD7 196SD8 196SD9 16" 196SD10 17" 196SD11 18" 196SD71 19" 196SD13 E " JAY Cushins (Optinal T rder any JAY cushins n-chair, please see the JAY price list. Cushin name r part number must be filled ut with desired width and depth JAY Bundled Cushin 196JC20 Cushin Name r Part # Price List Width: Depth: Frame Width - Built 4 Me Optins Weight Capacity 300 lbs. Nt available with EXO standard r Tensin adjustable uphlstery, Nt available with Ballistic Nyln r 3DX Tensin adjustable uphlstery. 196W59 196W60 196SL1 196SL6 E2201 B4ME - 21" Width E2201 B4ME - 22" Width Seat Sling Standard Seat Sling Omit Seat Sling -$15.00 Quickie QXi, Ultra Lightweight Adjustable Flding Wheelchair 196QC01 196QC02 196QC03 Custm Seating Surefit Cnfigurfit JayFit Quickie QXi featuring the Jay ION cushin Custmer Service: Fax: Page 1

2 3. CASTERS / SEAT HEIGHT Frnt Seat Height See Frnt Seat Height Matrix & 13.0 nly available w/ 60 hanger 12.5" & 13" nly available w/ Alum Angle Adj Ftplate 196SH " 196SH " 196SH " 196SH " 196SH " 196SH " 196SH " 196SH " 196SH " 196SH " 196SH " 196SH " 196SH " 196SH " 196SH " 196CS1 196CS5 196CS9 Caster Stem Blt Standard 3/4" 1 1/2" Frnt Seat Height Matrix 196CW3 196CW44 196CW5 196CW7 196CW34 196CW35 196CW32 196CW39 Caster Wheels 4" Lw Prfile Plyurethane 4" x 1.25" Semi Pneumatic $ " Lw Prfile Plyurethane 5" x 1.5" Semi Pneumatic 6" Plyurethane 6" x 1.5" Semi Pneumatic 8" Plyurethane 8" x 1.5" Semi Pneumatic 196CF71 196CF12 196CF17 196CF23 Caster Frk 3.5" (standard stem blt nly 5.25" 6" 7" 4. REAR WHEELS / REAR SEAT HEIGHTS Rear Seat Height Rear Seat Height Matrix See Rear Seat Height Matrix Rear Wheel Size Std Frame Hemi Frame 196RH9 12" 20" Rear Wheel 13.0" " 12.0" " 196RH10 196RH11 196RH12 196RH13 196RH14 196RH " 13" 13.5" 14.5" 22" Rear Wheel 24" Rear Wheel 25" Rear Wheel 26" Rear Wheel 14.0" " 15.0" " 15.5" " 16.0" " Rear Wheel Tire 12.5" " 13.5" " 14.0" " 14.5" " 196RH " See Rear Tire & Wheel Matrix fr availability 196RH17 16" 196RH " 196RT1 Pneumatic 196RH19 17" 196RT2 Pneumatic w/ Airless Insert 196RH " E RH20 18" 196RT3 Full Ply 196RH " 196RT39 High-Pressure Clincher Black 196RH21 19" E2212 $ RT21 Schwalbe Marathn Plus Evlutin Rear Wheel Size E2212 $ See Rear Tire & Wheel Matrix fr availability 196RW3 20" Mag Wheel Handrim 196RW8 22" Mag Wheel Natural Fit nly available w/ 22, 24, 25 Lite Spke. Plastic N/A w/ 25, 26" 196RW1 24" Mag Wheel See Apendix fr Rear wheel / Handrim matrix 196RW103 20" Mag Wheel 5 Spke 196HR1 Aluminum Andized 196RW104 22" Mag Wheel 5 Spke 196HR4 Plastic 196RW102 24" Mag Wheel 5 Spke 196HR22 Natural Fit - Standard Grip 196RW90 20" Lite Spke Wheel $ HR23 Natural Fit - Super Grip $ RW91 22" Lite Spke Wheel $ HR32 Natural Fit - N Thumb Grip $ RW92 24" Lite Spke Wheel 196HR26 The Surge - Oval w/griptin Strip $ RW93 25" Lite Spke Wheel $ HR27 The Surge LT - Oval w/griptin Strip $ RW94 26" Lite Spke Wheel $ HR28 Q-Grip Neprene Cated $ RW25 Omit Seat Squeeze Matrix Frame Depth Max Seat Squeeze 2.0" - 16" 2.5" 17" - 18" 2.5" 19" - 20" 3.0" Custmer Service: Fax: Page 2

3 4. REAR WHEELS / REAR SEAT HEIGHTS (CONT Rear Tire & Wheel Matrix 196AX1 196AX11 196AX45 Axle Quick Release Steel Quad Quick Release Steel N/A n Spke Threaded Axle $ AS4 196AS5 196AS6 Adjustable Axle Optins Adjustable sleeve Fixed Sleeve 0⁰ Fixed Sleeve 3⁰ One Arm Drive Available nly with 24" MBL Lite spke wheels. Std Aluminum black handrim 196AL16 E0958 One Arm Drive Adj. Axle Plate $ HM1 Right Hand Munt 196HM2 Left Hand Munt Center f Gravity Measure frm frnt f back pst t center f rear axle 196CC2 1" 196CC3 1.5" 196CC4 2" 196CC5 2.5" 196CC6 3" 5. WHEEL LOCKS 196WL1 196WL2 196WL30 196WL24 196WL23 196WL10 196WL12 Wheel Lck High Munt Push High Munt Pull Cmpact Unilateral Wheel Lck Right Unilateral Wheel Lck Left Omit Wheel Lck D Nt Munt $ $ $ Extensin Handle Ext. handles nly available with high munt push r pull wheel lcks 196EH7 E0961 Extensin Handle (Pair $ HANGERS AND FOOTRESTS Frnt Hangers Ftplate munts with Extensin Tube using clamping hardware 196H Swing In/Out Hanger 196H Swing In/Out Hanger 196H Swing In/Out Hanger 196H H H H144 K0053 E0990 E0990 Articulating Hanger N/A w/ Alum Angle Adj Frnt Munt ftplates. Elevating Hanger - Ext Munt N/A w/ Alum Angle Adj Frnt Munt ftplates. Elevating Hanger - Frnt Munt Only available w/ frnt munt alum angle adj ftplates and -22" width Omit Hanger & Ftplate $ Extensin Tubes See Lwer Leg Length Matrix fr range 196E1 Shrt 196E2 Medium 196E5 Lng Ftplate Heel lp nt included, see Ftplate Optin sectin belw 196F1 Cmpsite Ftplate 196F271 K0040 E0951 Cmpsite Angle Adj (16"-22"w 196F3 K0040 Aluminum Angle Adj. Ftplate 196F5 Aluminum Only available w/elevating Legrest 196HL A02 Hanger & Ftplate Optins E0951 Adjustable Heel Lp Gel Cver Fr Hangers (Pair $ $ $35.00 $ BACKREST / SEATING 196BT10 196BT B5 196B9 Back Type Standard Angle Adjustable Back Backrest Height Med (13"-17" Tall (16"-20" $ Push Handles Integral Push Handles, Flding Height Adjustable & Omit is 8 fr Standard Backrest, Straight fr Angle Adj. Backrest 196PH6 Integral Push Handles 196PH5 Fld-Dwn Push Handles Only available with Adjustable Uphlstery. Used in cmbinatin w/angle Adjust nly avail in 16"-20" back height 196PH17 196PH2 Flding Push Handle with Ht. Adj. Back Omit Push Handles $ Custmer Service: Fax: Page 3

4 7. BACKREST / SEATING (CONT 196BU1 196BU88 196BU70 196BU71 196BU89 196BU14 196JB01 Back Uphlstery Standard Uphlstery Standard Uphlstery EXO Backrest Tensin Adj Ballistic Nyln *Reference 186BU70 fr billing Backrest Tensin Adj 3DX Vented *Reference 186BU71 fr billing $ Backrest Tensin Adj EXO *Reference XXXBU89 fr billing $ Omit Back Uphlstery -$15.00 JAY Backs JAY Back (see Order frms Price List 196VU1 196VU2 196VU3 196VU4 196VU12 196VU5 196VU8 196VU9 196VU10 196VU11 196VU13 Military Service Patches US Marines Patch US Army Patch US Navy Patch US Air Frce Patch US Cast Guard Purple Heart Purple Heart with Marines Patch Purple Heart with Army Patch Purple Heart with Navy Patch Purple Heart with Air Frce Patch Purple Heart with Cast Guard 8. ARMREST / SIDEGUARDS Armrest - Padded Swing Away Sme limitatins when used with the Angle Adjustable Back in the rear mst setting Please circle a setting, will default t 11" if n selectin is made Padded Swing-Away STD (9" t 13" $ AA18 Setting 9" 10" 11" 12" 13" Armrest - Height Adjustable Flip Back HA Classic N/A w / - depth 196AA AA105 Single Pst Ht. Adj - Std (9.75"-14.75" Single Pst Ht Adj - Lw (8.25"-12.25" $ $ SG33 K0108 Side Guards Plastic - Standard (8.5" High 196AA65 Flip Back Ht Adj LITE (10"- 196SG29 K0108 Plastic - Lw (6.5" High 196AA AA AA14 Dual Pst Flip Back Ht Adj Flip Back Ht Adj Classic (11"- Omit Armrest $ AM23 196AM A01 Armpad - Fr Height Adjustable Desk Length (10" Full Length - Full ( Armrest Optins Gel Cver Fr Swing Away Arms (pair $ KEY OPTIONS 196AT1 196A1 1961A01 196A A804 E0971 E0978 Anti Tips Spke Guards Anti Tips (Pair $ A A02 K0065 K0065 Quickie Black Spke Guard Quickie Clear Spke Guard $ $ Pack Accessries Backpack - Black/Charcal Adult $75.00 Miscellaneus Seat Puch Black 1968A03 Caddy 196A2100 E2207 Crutch Hlder $ Psitining Belt 1.5" Aut Buckle w/ Clamps $70.00 Psitining Belt Slide Clamps 10. COLOR Standard Frame Clrs Matte Frame Clrs 196C140 Aztec Gld 196C116 Matte Black 196C2 Black (Nt avail as base w/zebra 196C151 Matte Black Cherry 196C141 Black Cherry 196C150 Matte Electric Blue 196C10 Black Opal 196C149 Matte Evergreen 196C38 Blue Opal 196C152 Matte Purple 196C36 Candy Blue 196C14 Candy Purple Custm Frame Clr 196C35 Candy Red 196C112 Desert Camuflage 196C142 Electric Blue 196C43 Mssy Oak Camuflage 196C143 Evergreen 196C42 Stars & Stripes 196C126 Glw Zebra (Chse abve base clr Std 196C144 Green Apple with White unless abve base paint is 196C C147 Ht Sparkle Pink chsen N/A w/ Blk, Matte Black, Blk Opal, Titanium 196C148 Mauve Pink 196C103 Rtbeer 196C114 Sparkle Silver Additinal Optins Thrugh Built fr Me 196C145 Sunrise Orange T inquire abut any unique custmizatin fr Quickie prducts, cntact: Phne: 196C113 Titanium Clr Paint ( , Fax: ( C8 Yellw Custmer Service: Fax: Page 4

5 APPENDIX Frnt Seat Height Matrix Cnt. Lwer Leg Length Range Matrix Sunrise Medical (US LLC 2842 Business Park Ave. Fresn, CA USA Custmer Service: Fax: Page 5