Quickie IRIS SE. November 2012

Transcription

1 Mark Fr: Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Cnfirmatin Cnfirm Via: PO#: ZIP: Quickie IRIS SE Nvember 2012 EIZ4-2 Submitting fr: Qute Order Ship T: Attentin: Address: Address: Ship T City: ADDITIONAL SHIPPING INFMATION Fax Ship T Phne: ( ) 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. Optin # HCPCS a Definitin Price Optin # HCPCS Definitin Price 1. FRAME STYLE & SETUP ST: ZIP: Pre-Set Tilt Angle (55 range) (Default in Bld) 183TA5 E t 50 NA w/ Heavy Duty and 12.5" STFH 183TA6 E t TA7 +5 t 60 NA w/heavy Duty Package Pre-Set Tilt Angle (40 range) (Default in Bld) 183TA8-5 t 35 NA w/ Heavy Duty and 12.5" STFH 183TA1 0 t TA10 +5 t 45 NA w/heavy Duty Package 183FS23 183HV2 183TT8 183WM57 Vent/Battery Tray Base 183FS24 E1029 NA w/ 14" and 15" frame width; minimum 17" STFH. NA w/ Attendant $ Wheel Lck. 183FT46 183TT12 183TO38 Base Mdel Quickie IRIS SE Frame Optins Standard Base and Seat Frame Maximum Weight: 250 lbs. Heavy Duty Package (Max: 350 lbs) NA w/ Vent and Battery Tray Cntracture Seat Frame NA w/ 14" r 15" frame depths. NA w/ drp seat pan. Tilt Release Optins Ft Release - N Cables NA with Vent and Battery Tray. NA with 21-22" depth and +5 set-ups. Left Right (Facing frm rear) Backrest Dual trigger cable releases Transit Transit Optin Heavy Duty w/ Transit nly available w/ 8" x 2" casters $2, $ $ Frame Width 183W5 183W6 183W7 183W9 14" 15" 16" 18" 183W8 183W10 19" 183W11 E " $ E W12 E " NA w/ remvable strller handle extensin $ W13 E " NA w/ remvable strller handle extensin $ Frame Clr 183C2 Black 183C10 Black Opal 183C38 Blue Opal 183C36 Candy Blue 183C14 Candy Purple 183C35 Candy Red 183C128 Cpper 183C6 Frest Green 183C127 Fuchsia 183C126 Glw 184C116 Matte Black 184C117 Matte Green 183C4 Midnight Purple 183C5 Pearl Pink 183C103 Rtbeer 183C114 Sparkle Silver 183C113 Titanium Clr Paint 183C11 Txic Green 183C8 Yellw Custm Frame Clr 183C112 Desert Camuflage $ C43 Mssy Oak Camuflage $ C42 Stars & Stripes $ Zebra (Chse abve base clr) Std 183C108 with White unless abve base paint is $ chsen NA w/ Black DER INFMATION: Custmer Service: Fax: Specificatins are subject t change withut ntice. Cpyright 2011 Sunrise Medical (US) LLC. (9.09) Quickie IRIS SE July 2012, REV. P Page 1

2 Optin # HCPCS a Definitin Price Optin # HCPCS Definitin Price 2. FRAME DEPTH SET UP (Fill ut either A r B) A. Setup By QUICKIE B. Setup By DEPTH A. User's Seated Height See Figure 1.2, Dimensin B. Distance frm seat surface t tp f the head. 183SJ01 Less than 37" 183SJ02 37" r Greater B. Frame Depth Range 183FL91 Shrt Seat Frame 14"-18" 183FL92 Medium Seat Frame 16"-20" 183FL93 Lng Seat Frame 18"-22" A. User's Weight (Default in Bld) lb ptins nly available w/ HD Package 183BO lbs 183BO lbs 183BO lbs A. Backrest Psitin See FIGURE 1.1 and FIGURE 1.3, Dimensin C. The lcatin f the backrest surface in relatin t the frnt f the backpst. The measurement is taken frm the frnt surface f the backpst t the deepest area f the backrest in cntact with the user's bdy. 183BQ01 183BQ05 183BQ02 183BQ03 183BQ04 183BQ06 +3" +2" +1" Flush -1" -2" B. Frame Depth recmmend shrt seat frame 183FD5 183FD6 15" recmmend shrt seat frame 183FD7 16" recmmend shrt seat frame 183FD8 17" recmmend shrt seat frame 183FD9 18" recmmend medium seat frame 183FD10 19" recmmend medium seat frame 183FD11 E " recmmend lng seat frame $ FD16 E " recmmend lng seat frame $ FD17 E " recmmend lng seat frame $ A. Figures fr Setup by Quickie Figure 1.2 A. Tp f Cushin t Seat Rail See FIGURE 1.4 Dimensins A & B. This measurement is taken frm the tp f the cushin t the upper surface f the seat rail. If the cushin has a wedged shape and/r has significant lateral pelvic cntur, then determine the height f the cushin at the pint where the ischial tubersities wuld cntact (nt immerse) the cushin surface. 183CJ04 183CJ05 183CJ03 2 1/2" r Greater Less than 2 1/2" Belw Seat Rail Desired Seat Depth A. Desired Seat Depth See fr pricing, Figure 1.2, Dimensin A fr measurement 183SD7 183SD8 183SD9 14" 15" 16" 183SD10 183SD11 183SD12 183SD13 183SD14 183SD15 E2203 E2203 E " 18" 19" 20" 21" 22" Figure 1.3 Figure SEATING 183ST35 183ST36 183ST54 Seat Type Standard Seat Pan E2231 Fr grwth ranges, see Figure 1.5 Drp Seat Pan NA w/ transit, HD, E2231 cntracture ftrest system Omit Seat Pan $ $ 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 183JC20 Cushin Name/Part #: Price List Width: Depth: Figure 1.5 Frame Width Seat Pan Grwth 14" 14" - 16" 15" 15" - 16" 16" 16" - 18" 17" 17" - 18" 18" 18" - 20" 19" 19" - 20" 20" 20" - 22" 21" 21" - 22" 22" NA DER INFMATION: Custmer Service: Fax: Specificatins are subject t change withut ntice. Cpyright 2011 Sunrise Medical (US) LLC. (9.09) Quickie IRIS SE July 2012, REV. P Page 2

3 Optin # HCPCS a Definitin Price Optin # HCPCS Definitin Price 4. BACKREST Backpst Style - (Chse ONE Optin - A, B, r C) A. Strller Handle Backpst (Fixed) 183BP9 Lw (18") 183BP10 183BP11 Medium (21") Tall (24") Remvable Extensin NA w/ 21"- 183BP13 22" frame width, height adj back with adj strller handles A 183BT JB01 Dynamic Backrest Dynamic Backrest NA w/ Reclining Backrest r 19"-22" seat depths JAY J3 Back JAY J3 Back NA w/ O2 Hlder $1, See OF B. Height Adjustable Back w/ Adj. Strller Handles Select desired Push Handle 183PH8 Standard Push Handle 183PH9 Lng Push Handle Recmmended in cmb w/ vent & battery tray AND select desired Back Cane 183B B201 Standard 15"-21" Tall 18"-24" B C. Reclining Backrest (0-50 ) Nt available with 22" Deep Frame 183BT21 E1225 Reclining Backrest 183B5 183B9 Medium Tall $ C 5. ARMREST Height Adj. Handle Height Diagram Reclining/Fixed Han Armrest Heavy Duty Optin nly available w/ Dual Pst Armrest 183AA63 E0973 Dual Pst Height Adjustable 183AA43 183AA62 183AA48 E0973 Dual Pst Flip Back Dual Pst Dual Pst Flip Back Height Adj $ AA7 E0976 Length Adjustable Lcking Flip-Up NA w/ cntur armpad $ AA11 E0973 Single Pst Height Adjustable - Std $ AA29 E0973 Single Pst Height Adjustable - Lw $ AA1 E0973 Adjustable Lcking Flip-Up 183AA14 Omit Armrest Armrest Receiver (Single Pst Height Adjustable Only) 183AR17 Lw 183AR18 Std Armpad 183AM23 Desk Length Classic 183AM21 183AM24 Desk Length Cntur Full Length Classic 183AM22 Full Length Cntur 183AM24 Full Length Classic 183AM9 Fam Shrt Optin fr Length Adj Lcking Flip Up 183AM10 Fam Lng Optin fr Length Adj Lcking Flip Up Armrest Size 8" LOW 5 1/4" Armrest Matrix fr Single Pst Classic Pad Transfer Tube Receiver Pad Length L Length D H Range Desk Full LOW 10 3/4" t 15 3/4" 8 3/4" t 13 3/4" 9" t 13" 10" t 15" LOW 8 1/4" t 12 1/2" 8 1/2" t 12 1/2" LOW 6 3/4" t 10 3/4" 10 1/4" 14" LOW 7 1/4" t 11 1/4" Cntur Pad Receiver Pad Length L H Range Desk Full 10 1/2" 14 1/4" DER INFMATION: Custmer Service: Fax: Specificatins are subject t change withut ntice. Cpyright 2011 Sunrise Medical (US) LLC. (9.09) Quickie IRIS SE July 2012, REV. P Page 3

4 Optin # HCPCS a Definitin Price Optin # HCPCS Definitin Price 6. HANGER AND FOOTPLATE OPTIONS Ftrest (Chse ONE Optin - A, B, r C) A. Hanger Munted Ftrest 183H89 183H90 183H91 70 Swing In/Swing Out -Frnt Munt 80 Swing In/Swing Out -Frnt Munt 90 Swing In/Swing Out -Frnt Munt 183H Heavy Duty Frnt Munt Lift Off 183H Heavy Duty Frnt Munt Lift Off NA w/ 4" casters 183H Heavy Duty Frnt Munt Lift Off NA w/ 4" casters 183H23 E Elevating NA w/ 6" casters r 90 ftbard A. Hanger Munted Ftrest Extensin Tubes NA w/ 12.5" seat height 2" 183E23 NA w/ 90 swing away, lift ff hangers 4" 183E24 NA w/ 90 swing away, lift ff hangers 183F4 K0040 A. Hanger Munted Ftrest Ftplates Heel lp r leg strap nt included, See Ftplate Optins Sectin Kids Angle Adj Available w/ 14" t 16" frame width nly $ $55.00 $55.00 $ F3 K0040 Adult Angle Adj $ A7 Omit Ftplate A C. Cntracture Ftrest System Multi-Adjustable Padded Hangers & Angle Adjustable Aluminum Ftrests Cntracture Ftrest System NA w/ 183H26 drp seat pan. NA w/ 15" frame $ depth 183FP02 Outside Munt 183FP01 Center Munt Select Extensin Height Belw fr Shrt 183E25 Shrt 183EP1 10.5" Extensin Height 183EP2 11.0" Extensin Height 183EP3 11.5" Extensin Height C 183EP4 12.0" Extensin Height 183EP5 12.5" Extensin Height 183EP6 13.0" Extensin Height Select Extensin Height Belw fr Regular 183E26 Regular 183EP5 12.5" Extensin Height 183EP6 13.0" Extensin Height 183EP7 13.5" Extensin Height 183EP8 14.0" Extensin Height 183EP9 14.5" Extensin Height 183EP " Extensin Height B. Extensin Tube Munted Ftrests Ftrests munt t extensin tubes 183H85 183H86 60 Swing In/Swing Out 70 Swing In/Swing Out 183H Swing In/Swing Out NA w/ 8" casters 183H14 E0990 Elevating Only available w/ alum r angle adj ftplate 183H24 K0053 Articulating Adult NA w/ shrt ext tubes B. Extensin Tube Munted Ftrests 183E1 Shrt (11.5" - 14") 183E2 Medium (14" - 17") NA with 12.5" seat height 183E5 Lng (17" - 19") NA with 12.5" seat height 183E12 Shrt ELR (ELR nly 11.5" " ) 183E15 Lng ELR (ELR nly 12.5" ") 183E16 K0037 High Munt Only available with adult r kids angle adj. ftplates 183F3 B. Extensin Tube Munted Ftrest Ftplates Heel lp r leg strap nt included, See Ftplate Optins Sectin 183F1 183F5 K0040 Cmpsite with 70 SA ext. munt hangers NA w/ 8" casters Aluminum Only available w/elr Adult Angle Adjustable $ $ $55.00 $ B Additinal Hanger and Ftplate Optins Hanger Munts Nt available with preset tiltangle Pssible interferance with 80 & 90 hangers 183MZ02 Standard Hanger Munt 183MZ01 1" Offset Hanger Munt Ftrest Optins 183HL1 183HL5 E0951 K0038 Heel Lp Leg Strap $30.00 $35.00 Impact Guard Neprene 183IG2 Only available w/ 60 r 70 ext. munt hanger 183H32 Omit Hanger -$ HL4 Omit Heel Lp 183HL6 Omit Single Leg Strap 183F48 183F7 K0040 Platfrm Flip-Up NA w/ med ext tubes. Only available with 60 r 70 hangers Omit Ftplate and Ext. Tube $ $15.00 DER INFMATION: Custmer Service: Fax: Specificatins are subject t change withut ntice. Cpyright 2011 Sunrise Medical (US) LLC. (9.09) Quickie IRIS SE July 2012, REV. P Page 4

5 Optin # HCPCS a Definitin Price Optin # HCPCS Definitin Price 7. SEAT HEIGHT SETUP Rear Wheel Size 12" Mag 12" Lw Ply 16" Mag 20" Mag 22" Mag 24" Mag & Spke Frnt Seat Height 12.5" 13.5" 16.5" 16.5" E RT1 16.5" 17.0" 17.0" 17.0" E " 17.5" 17.5" 17.5" 17.5" E RT2 17.5" 18.0" 18.0" 18.0" E2211 Pneumatic Pneumatic Airless Insert $ " 16.0" 16.0" 16.5" 16.5" 16.5" 16.5" 16.5" Handrim 17.0" 17.0" 17.0" 17.0" 17.0" 12" and 16" wheels nt available with hand rims. 17.5" 17.5" 183HR1 Aluminum Andized 13.5" 183HR4 Plastic Cated 14.0" 183HR7 Omit Handrim 14.5" 14.5" 15.0" 15.0" Prjectins 18.0" 18.0" 18.0" 18.0" 18.0" Nt available n plastic cated. Only available with 24" rims. 18.5" 18.5" 18.5" 18.5" 183HR8 8 Oblique $ " 19.0" 19.0" 19.0" 19.5" Axle 16.0" 17.0" 16.0" 17.0" 17.0" 16.0" 17.0" 17.0" 16.5" 17.5" 16.5" 16.5" 17.5" 16.5" 16.5" 183AX1 183AX " 17.0" 17.0" 17.0" 17.5" 17.5" 17.5" 17.5" 18.0" 18.0" 18.0" 18.0" 18.0" 18.5" 18.5" 18.5" 18.5" 18.5" 18.5" 18.0" 18.0" 18.0" 18.0" 183AL " 19.0" 19.0" 19.0" 19.5" Casters 183CW73 4" x 1.25" Semi Pneumatic NA w/ Heavy Duty Optin 183CW53 183CW7 183CW45 5" x 1" Plyurethane 5" x 1.5" Semi Pneumatic 6" x 1" Plyurethane 183CW35 6" x 1.5" Semi Pneumatic 183CW39 8" x 1" Plyurethane 183CW39 8"x 1.5" Semi Pneumatic 183CW36 E2214 E2215 8"x 2" Pneumatic $ CW37 E2214 K0108 4" 5" 8"x 2" Pneumatic w/insert Rear Wheel CASTER SIZE 6" 8x1" 8x1.5" 8x2" $ RT3 Rear Wheel Tire Full Plyurethane Lw Plyurethane Only available w/ 12" Mag Wheel Quick Release Axles NA w/ ne arm drive Threaded Axles NA w/ 24" spke wheels 183RT4 Axle Plate 183AL33 Standard Axle Plate E0958 One Arm Drive Axle Plate NA w/ 12" & 16" mag, 24" spke wheels. $ OA2 One Arm Drive Standard Handrim 183HM1 Right Hand Munt 183HM2 Left Hand Munt 183OA1 One Arm Drive Small Handrim NA w/ 20" mag wheels 183HM1 183HM2 Right Hand Munt Left Hand Munt Hub Lck Only available w/ 12" r 16" wheels. NA w/ ne arm drive. 183LK01 12" Hub Lck $ LK02 16" Hub Lck $ Wheel Lck 183WL8 Push t Lck Attendant Wheel Lck (Ft Lck) 183WL41 E2206 NA w/ ext handles. NA w/ ne arm $80.00 drive 183WL10 Omit Wheel Lck 183RW13 183RW14 12" Mag Wheel NA w/ hand rims and full ply tires. With attendant wheel lck NA w/ tilt angle. 16" Mag Wheel NA w/ hand rims, pneumatic r pneumatic w/ airless inserts tires. 183RW3 20" Mag Wheel NA w/ prjectin handrims. 183RW8 22" Mag Wheel NA w/ prjectin handrims. 183RW1 183RW51 24" Mag Wheel 24" Spke Wheel $ EH5 E0961 Extensin Handle Fld Dwn NA w/ attendant wheel lck $60.00 DER INFMATION: Custmer Service: Fax: Specificatins are subject t change withut ntice. Cpyright 2011 Sunrise Medical (US) LLC. (9.09) Quickie IRIS SE July 2012, REV. P Page 5

6 Optin # HCPCS a Definitin Price Optin # HCPCS Definitin Price 8. KEY OPTIONS AND ACCESSIES Anti Tips Included with vent tray ptin. Nt rdered as separate line item. 183AT1 E0971 Anti Tips (Pair) $ Additinal Optins Thrugh Built fr Me T inquire abut any unique custmizatin fr Quickie prducts, cntact: Phne: (800) , Fax: (800) Seat Puch 183A8 Black $45.00 Backpack 183A1 Black Utility Backpack $55.00 Extra Leg Strap 183A54 Black $30.00 Cmmnly Requested Optins Include: 23" & 24" Seat Widths Angle Adjustable Handle fr Reclining Backrest Miscellaneus Accessries 183A82 Caddy Only available w/ extentin tube munted ftrests $ A71 183A73 K0105 O2 Hlder NA w/ Height Adj Strller E2208 Handles. NA w/ Reclining Backrest, r Transit Optin. IV Ple NA w/ transit ptin $ $ Psitining Belt 183A158 E0978 2" Dual Pull Squeeze Pad w/clamp 183A141 E " Aut Buckle Universal w/clamp $70.00 $ A117 E0978 2" Aircraft Buckle w/clamps 183A118 E0978 2" Aircraft Buckle Pad w/clamp $ A120 K0108 Psitining Belt Clamps Only $50.00 Spke Guards Nt available with 12" and 16" mag wheels. 183A24 183A23 K0065 K0065 Clear Black NA w/ prjectin handrims $ $ Wheelchair Tray Table Only available if armrests are included. 183A30 183A31 183A32 183A33 Small (13"-14") Medium (15"-17") Large (18"-20") X-Large (21"-22") Side Guard Only available with length adjustable lcking flip-up and adjustable lcking flip-up armrest styles. 183SG3 183SG4 K0108 K0108 Plastic Regular Plastic Kids $ $ DER INFMATION: Custmer Service: Fax: Specificatins are subject t change withut ntice. Cpyright 2011 Sunrise Medical (US) LLC. (9.09) Quickie IRIS SE July 2012, REV. P Page 6