Quickie IRIS March 2016

Transcription

1 a Mark Fr: Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Cnfirmatin Cnfirm Via: Optin # HCPCS ZIP: Quickie IRIS March 2016 Qute Fax Ship T Phne: ( ) Fax: ( ) Definitin EIZ FRAME a Submitting fr: Optin # PO#: Ship T: Attentin: Address: Address: Ship T City: HCPCS ST: ADDITIONAL SHIPPING INFMATION Definitin Order 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. ZIP: Base Mdel 183WM56 E1161 Quickie IRIS with True Fit Grwth Fr 14" sizes use E1233 $2, TO45 Transit WC-19 Transit Optin $ 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 E t 60 NA w/heavy Duty Package Pre-Set Tilt Angle (40 range) (Default in Bld) 183TA8 E t 35 NA w/ Heavy Duty and 12.5" STFH 183TA1 E t TA10 E t 45 NA w/heavy Duty Package 183FS23 183HV1 183FS24 183FT46 E1029 Frame Optins Standard Base and Seat Frame Maximum Weight: 250 lbs. Heavy Duty Package (Max: 350lbs) NA w/ Vent, Battery Tray and Mn Back Vent/Battery Tray Base NA w/ Attendant Wheel Lck, Mn Back and 14" and 15" frame width; min 17" STFH. Cntracture Seat Frame NA w/ 14" r 15" frame depths. NA w/ drp seat pan. $ $ TT8 183TT12 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 183GY01 183GY02 Frame Struts Fixed (Standard) Width Adjusting System Avail. range 14"-21". Max grwth 22" NA with Mn Back $ SIZE / SEATING Frame Width 183W5 14" 183W6 15" 183W7 16" 183W8 17" 183W9 18" 183W10 19" 183W11 E " 183W12 E " NA w/ remvable strller handle extensin 183W13 E " NA w/ remvable strller handle extensin $ $ $ Seat Type 183ST35 E2231 Standard Seat Pan Fr grwth ranges, see Figure 1.5 $ ST36 Drp Seat Pan NA w/ transit, HD, cntracture ftrest system $ ST54 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 #: List Width: Depth: 183QC01 183QC02 Custm Seating Surefit Cnfigurfit Specificatins are subject t change withut ntice. Cpyright 2011 Sunrise Medical (US) LLC. Quickie IRIS, MK REV H Page 1

2 a Optin # HCPCS Definitin a Optin # HCPCS 2. SIZE / SEATING (CONT) Fill ut either A r B) Definitin A. Setup By QUICKIE B. Setup By DEPTH A. User's Seated Height B. Frame Depth Range See Figure 1.2, Dimensin B. Distance frm seat surface t tp f the head. 183FL91 Shrt Seat Frame 14"-18" 183SJ01 Less than 37" 183FL92 Medium Seat Frame 16"-20" 183SJ02 37" r Greater 183FL93 Lng Seat Frame 18"-22" A. User's Weight (Default in Bld) B. Frame Depth lb ptins nly available w/ HD Package 183FD5 14" recmmend shrt seat frame 183BO lbs 183FD6 15" recmmend shrt seat frame 183BO lbs 183FD7 16" recmmend shrt seat frame 183BO lbs 183FD8 183FD9 17" recmmend shrt seat frame 18" recmmend medium seat frame A. Desired Seat Depth 183FD10 19" recmmend medium seat frame See Figure 1.1 fr pricing, Figure 1.2, Dimensin A fr measurement 183FD11 E " recmmend lng seat frame $ SD7 14" 183FD16 E " recmmend lng seat frame $ SD8 15" 183FD17 E " recmmend lng seat frame $ SD9 16" 183SD10 17" Figure SD11 18" Figure SD12 19" Figure 1.1 Figure SD13 183SD14 183SD33 E2203 E2203 E " 21" 22" Figure 1.1 Figure 1.1 Figure 1.1 A. Tp f Cushin t Seat Rail See FIGURE 1.3 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. 183CJ01 183CJ02 183CJ03 2 1/2" r Greater Less than 2 1/2" Belw Seat Rail Desired Seat Depth Figure 1.2 Figure 1.3 Figure 1.4 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 3. CASTERS Casters 183CW73 4" x 1.25" Semi Pneumatic 183CW46 NA w/ Heavy Duty Optin 183CW53 5" x 1" Plyurethane 183CW7 5" x 1.5" Semi Pneumatic $ CW36 183CW45 6" x 1" Plyurethane 183CW35 6" x 1.5" Semi Pneumatic $ CW37 8" x 1" Plyurethane 183CW39 8"x 1.5" Semi Pneumatic $85.00 E2214 E2215 8"x 2" Pneumatic $ E2214 K0108 8"x 2" Pneumatic w/insert $ Specificatins are subject t change withut ntice. Cpyright 2011 Sunrise Medical (US) LLC. Quickie IRIS, MK REV H Page 2

3 a Optin # HCPCS Definitin a Optin # HCPCS 4. REAR WHEELS / SEAT HEIGHT Definitin Frnt Seat Height Rear Wheel Rear Wheel Size 12" Mag 12" Lw Ply 16" Mag 20" Mag 22" Mag 24" Mag & Spke CASTER SIZE 4" 5" 6" 8x1" 8x1.5" 8x2" 183RW " 13.5" 16.5" 16.5" 16.5" 17.0" 17.0" 17.0" 17.0" 17.5" 17.5" 17.5" 17" 183RW " 18.0" 18.0" 18.0" 13.5" 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" 183RW3 183RW8 183RW1 14.0" 14.5" 14.5" 15.0" 15.0" 18.0" 18.0" 18.0" 18.0" 18.0" 183RT3 18.5" 18.5" 18.5" 18.5" 19.0" 19.0" 19.0" 19.0" 183RT4 19.5" 16.0" 16.0" 16.0" 183RT1 16.5" 16.5" 16.5" 16.5" 16.5" 17.0" 17.0" 17.0" 17.0" 17.0" 183RT2 17.5" 17.5" 17.0" 17.0" 17.0" 17.0" 20" Mag Wheel NA w/ prjectin handrims. 22" Mag Wheel NA w/ prjectin handrims. 24" Mag Wheel 183RW51 24" Spke Wheel $ E2211 E2212 E2213 E " 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. Only avail w/pneumatic r pneumatic w/ airless inserts tires. Rear Wheel Tire Full Plyurethane Lw Plyurethane Only available w/ 12" Mag Wheel Pneumatic Pneumatic Airless Insert Handrim 17.5" 17.5" 17.5" 17.5" 12" and 16" wheels nt available with hand rims. 18.0" 18.0" 18.0" 18.0" 18.0" 183HR1 Aluminum Andized 18.5" 18.5" 183HR4 Plastic Cated 18.0" 18.0" 18.0" 18.0" 183HR7 Omit Handrim 18.5" 18.5" 18.5" 18.5" 19.0" 19.0" 19.0" 19.0" Prjectins 19.5" Nt available n plastic cated. Only available with 24" rims. 183HR8 8 Oblique $80.00 $95.00 $ Axle Plate 183AL33 Standard Axle Plate 183AL17 E0958 One Arm Drive Axle Plate NA w/ 12" & 16" mag, 24" spke wheels. $ OA2 One Arm Drive Standard Handrim 183HM1 183HM2 183OA1 Right Hand Munt Left Hand Munt One Arm Drive Small Handrim NA w/ 20" mag wheels 183HM1 183HM2 Right Hand Munt Left Hand Munt 183AX1 183AX17 Axle Quick Release Axles NA w/ ne arm drive Threaded Axles NA w/ 24" spke wheels 5. WHEEL LOCKS / HUB LOCK 183WL8 183WL41 183WL10 E2206 Wheel Lck Push t Lck Attendant Wheel Lck (Ft Lck) NA w/ ext handles. NA w/ ne arm drive Omit Wheel Lck $80.00 Hub Lck Only available w/ 12" r 16" wheels. NA w/ ne arm drive. 183LK01 183LK02 12" Hub Lck 16" Hub Lck $ $ Extensin Handle 183EH7 E0961 6" Pair $65.00 Specificatins are subject t change withut ntice. Cpyright 2011 Sunrise Medical (US) LLC. Quickie IRIS, MK REV H Page 3

4 a Optin # HCPCS Definitin a Optin # HCPCS 6. HANGER AND FOOTREST Definitin Ftrest (Chse ONE Optin - A, B, r C) A. Hanger Munted Ftrest Extensin Tubes NA w/ 12.5" seat height 2" NA w/ 90 swing away, 90 lift ff 183E23 hangers 183H H H H H H H E24 183F8 183A7 E0990 A. Hanger Munted Ftrest 70 Swing In/Swing Out -Frnt Munt 80 Swing In/Swing Out -Frnt Munt 90 Swing In/Swing Out -Frnt Munt 70 Heavy Duty Frnt Munt Lift Off 80 Heavy Duty Frnt Munt Lift Off NA w/ 4" casters 90 Heavy Duty Frnt Munt Lift Off NA w/ 4" casters Elevating Hanger - Frnt Munt NA 90 ftbard, sme interference with casters if nt tilted, 17" wide chairs & up. A. Hanger Munted Ftrest Ftplates Heel lp r leg strap nt included, See Ftplate Optins Sectin 183F4 K0040 $95.00 $95.00 $95.00 $ $ " NA w/ 90 swing away, 90 lift ff $55.00 Kids Angle Adj Available w/ 14" t 16" frame width nly K0040 Adult Angle Adj - Frnt Munt 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 183FP01 Outside Munt Center Munt Select Extensin Height Belw fr Shrt 183E25 Shrt 183EP1 183EP2 183EP3 183EP4 10.5" Extensin Height 11.0" Extensin Height 11.5" Extensin Height 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 Additinal Hanger and Ftplate Optins C B. Extensin Tube Munted Ftrests Ftrests munt t extensin tubes 183H Swing In/Swing Out 183H Swing In/Swing Out 183H Swing In/Swing Out NA w/ 8" casters 183H159 B. Extensin Tube Munted Ftrest Ftplates Heel lp r leg strap nt included, See Ftplate Optins Sectin 183F1 183H F5 E0990 K0053 Elevating Hanger - Ext Munt NA w/ Platfrm Flip Up and Alum Angle Adj Frnt Munt ftplates. Articulating Hanger NA w/ Platfrm Flip Up and Alum Angle Adj Frnt Munt ftplates. B. Extensin Tube Munted Ftrests 183E1 Shrt 183E2 Medium NA with 12.5" seat height 183E5 Lng NA with 12.5" seat height 183E16 K0037 High Munt Only available with adult r kids angle adj. ftplates 183F48 K0040 Cmpsite Aluminum Platfrm Flip-Up NA w/ med ext tubes. Only available w/elr 183F3 K0040 Adult Angle Adjustable - Ext Munt 183F7 $ $ $55.00 $ $ Omit Ftplate and Ext. Tube -$15.00 B Hanger Munts 1" Offset NA with and preset tilt angle and pssible interference with 80 & 90 hangers 183MZ02 Standard Hanger Munt 183MZ01 1" Offset Hanger Munt JAY FOOT BOXES Only available with Swing Away, Lift-ff Hangers, Adult Angle Adj Ftplates and ELR / ALR.Single Ft Bx pairs NA with 14"-15" frame widths. Full Ft Bxes NA with Heel Lp r Leg Strap, Tall Height Full Ftbx w/ 14"-15" frame width and ELR / ALR. Single Ft Bx 183JX01 Standard Height - Left $ JX02 Tall Height - Left $ JX03 Standard Height - Right $ JX04 Tall Height - Right $ JX05 Standard Height - Pair $ JX06 Tall Height - Pair $ Full Ft Bx 183JX07 Full Ft bx Std Height $ JX08 Full Ft bx Tall Height $ JX09 Full Ft bx w/ Divider Std Ht $ JX10 Full Ft bx w/ Divider Tall Ht $ HL1 183HL5 183IG2 183H32 183HL4 183HL6 Ftrest Optins E0951 Heel Lp K0038 Leg Strap Impact Guard Neprene Only available w/ 60 r 70 ext. munt hanger Omit Hanger Omit Heel Lp Omit Single Leg Strap $30.00 $35.00 $ $15.00 Specificatins are subject t change withut ntice. Cpyright 2011 Sunrise Medical (US) LLC. Quickie IRIS, MK REV H Page 4

5 a Optin # HCPCS Definitin a Optin # HCPCS 7. BACKREST / SEATING Definitin 183BT101 Dynamic Backrest Dynamic Backrest NA w/ Reclining Backrest r 19"-22" seat depths $1, JB01 JAY J3 Back JAY J3 Back NA w/ O2 Hlder See OF Backpst Style - (Chse ONE Optin - A, B, C, r D) 183BP9 183BP10 183BP11 183BP13 A. Strller Handle Backpst (Fixed) Lw (18") Medium (21") Tall (24") Remvable Extensin NA w/ 21"- 22" frame width, height adj back with adj strller handles $85.00 A C. Reclining Backrest (0-40 ) Only available with 40 degree tilt range. NA w/ 22" Deep Frame. 183BT21 E1225 Reclining Backrest 183B5 183B9 Medium Tall $ C 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 183B200 Standard 15"-21" 183B201 Tall 18"-24" B D. Mn Back System Must select JAY J3 r JAY Custm Back when rdering Mn Back System. Select One 183MO1 Mn Backrest System $ MO2 Mn Backrest System w/dynamic Backrest $ AND Select desired Push Handle 183PH8 Standard Push Handle D 183PH9 Lng Push Handle Reclining/Fixed Handle Ht. Diagram Height Adj. Handle Height Diagram Mn Height Adj. Handle Height Diagram Backrest Psitin (set up by Quickie) See FIGURE 1.5. 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 +3" 183BQ05 +2" 183BQ02 +1" 183BQ03 Flush 183BQ04-1" 183BQ06-2" Figure 1.5 Specificatins are subject t change withut ntice. Cpyright 2011 Sunrise Medical (US) LLC. Quickie IRIS, MK REV H Page 5

6 a Optin # HCPCS Definitin a Optin # HCPCS 7. BACKREST / SEATING (CONT) Definitin Mn Backrest Optins ONLY NA n HD, Vent/Battery Tray Base(LTV nly), Reclining Backrest, Desk Length Armpads and Canpy. JAY J3 Back fr Mn Backrest System JAY J3 Back fr Mn Backrest System Cnt. 183JB04 JAY J3 Back Mn See OF Select desired Headrest Munt (ptinal) 183JB05 JAY J3 Backrest Cntur JAY J3 via JAY Yur Way See OF 183MH10 183MH15 E1028 E1028 Axys Munt & Bracket Cbra Flip Back Munt and Bracket $ $ JP01 183JP02 E2613 E2614 J3 PA Back (2.2" f Cntur Depth) 183MH16 E1028 Onyx Munt and Bracket $ $ "-20" Wide J3 PA Back (2.2" f Cntur Depth) 183MH17 Omit $ " Wide Select desired Headrest Pad (ptinal) 183JP03 183JP04 183JP05 J3 PL Back (3.0" f Cntur Depth) 183HE65 E0955 Plush Head Supprt Pad 8" $ E2615 $ "-20" Wide 183HE66 E0955 Plush Head Supprt Pad 10" $ J3 PDL Back (6.0" f Cntur Depth) 183HE78 E0955 Plush Head Supprt Pad 14" $ E2620 $ "-20" Wide 183HE87 E0955 HeadsUp Lrg: 5.3" Lng Arms $ J3 PDC Back (6.0" f Cntur Depth) 183HE88 E0955 HeadsUp Med: 4.1" Sht Arms $ E2620 $ "-20" Wide 183HE89 E0955 HeadsUp Sml: 3.5" Sht Arms $ JAY J3 Backrest Height 183HE83 E0955 Adjust-A-Plush Standard $ JR07 183JR08 183JR09 UT Standard 16.5" shell height 183HE82 E0955 Adjust-A-Plush Narrw $ Select desired Lateral (ptinal) UT Medium 18" shell height LAT 4X4 S/A MOUNTS includes 1" OFFSET - PR $ ZV14 E0956 LATERAL 4X4 W/ 1" OFFSET - PAIR $ UT Tall 19.5" shell height 183ZS07 E1028 LATERAL SWING AWAY MOUNT - PAIR $ LAT 4X5 S/A MOUNTS includes 1" OFFSET - PR $ JR10 SH Standard 21" Shell Height 183ZV15 E0956 LATERAL 4X5 W/ 1" OFFSET - PAIR $ ZS07 E1028 LATERAL SWING AWAY MOUNT - PAIR $ JR11 183JR12 SH Medium 22.5" SH Tall 24" LAT 4X6 S/A MOUNTS includes 1" OFFSET - PR $ ZV16 E0956 LATERAL 4X6 W/ 1" OFFSET - PAIR $ ZS07 E1028 LATERAL SWING AWAY MOUNT - PAIR $ LAT 6X4 S/A MOUNTS includes 1" OFFSET - PR $ JAY J3 Backrest Width 183ZV17 E0956 LATERAL 6X4 W/ 1" OFFSET - PAIR $ Sme interference with armrest may exist when rdering a Backrest 183ZS07 E1028 LATERAL SWING AWAY MOUNT - PAIR $ with greater than 4" wider than the base. LAT 6X5 S/A MOUNTS includes 1" OFFSET - PR $ JQ06 12" Backrest Width 183ZV18 E0956 LATERAL 6X5 W/ 1" OFFSET - PAIR $ JQ01 14" Backrest Width 183ZV07 E1028 LATERAL SWING AWAY MOUNT - PAIR $ JQ02 16" Backrest Width LAT 6X6 S/A MOUNTS includes 1" OFFSET - PR $ JQ03 183JQ04 183JQ05 JAY J3 Backrest Clr 18" Backrest Width 20" Backrest Width 22" Backrest Width 183ZV19 183ZS07 E0956 LATERAL 6X6 W/ 1" OFFSET - PAIR E1028 LATERAL SWING AWAY MOUNT - PAIR $ $ GZ01 183GZ02 183GZ03 Black Matching Frame- Standard Clrs Matching Frame- Custm Clr $ ARMREST / SIDE GUARDS Armrest Heavy Duty Optin nly available w/ Dual Pst Armrest 183AA63 E0973 Dual Pst Height Adjustable 183AA43 Dual Pst Flip Back 183AA62 Dual Pst 183AA48 E0973 Dual Pst Flip Back Height Adj 183AA11 E0973 Single Pst Height Adjustable - Std 183AA29 E0973 Single Pst Height Adjustable - Lw 183AA7 E0973 Length Adjustable Lcking Flip-Up NA w/ Cntur Armpad 183AA1 183AA154 E0973 Adjustable Lcking Flip-Up Height Adj. Cantilever Armrest E0973 Available with Mn Back nly. NA w/ 20", 22" and 24" rear wheels. $ $95.00 $ $ $ $ $ $ AM23 183AM21 183AM24 183AM22 183AM9 183AM10 Armpad Desk Length Classic Desk Length Cntur Full Length Classic Full Length Cntur Fam Shrt Optin fr Length Adj Lcking Flip Up Fam Lng Optin fr Length Adj Lcking Flip Up 183AA14 Omit Armrest Armrest Receiver (Single Pst Height Adjustable Only) 183AR17 Lw 183AR18 Std Specificatins are subject t change withut ntice. Cpyright 2011 Sunrise Medical (US) LLC. Quickie IRIS, MK REV H Page 6

7 a Optin # HCPCS Definitin a Optin # HCPCS 8. ARMREST / SIDE GUARDS (CONT) Definitin JAY Arm Trughs NA with Length Adj. Lcking Flip Up and Adj Lcking Flip Up armrests and Single Pst Height Adj Armrests. F ull Lentgh Classic Armpads will autmatically be selected when chsing nly ne side Arm Trugh. 183JL01 E2209 Arm Trugh - 14" lng - Left $ JL04 E2209 Arm Trugh - 14" lng - Right $ JL05 E2209 Arm Trugh - 14" lng - Pair $ JL02 E2209 Arm Trugh - 18" lng - Left $ JL06 E2209 Arm Trugh - 18" lng - Right $ JL07 E2209 Arm Trugh - 18" lng - Pair $ JL03 E2209 Arm Trugh - 22" lng - Left $ JL08 E2209 Arm Trugh - 22" lng - Right $ JL09 E2209 Arm Trugh - 22" lng - Pair $ JAY Arm Trugh - Hardware 183JN01 Fixed (EA) 183JN03 Fixed (Pair) 183JN02 E1028 Swing Away - Rtatinal (EA) $ JN04 E1028 Swing Away - Rtatinal (Pair) $ Side Guard Only available w/ length adj lcking flip-up, adj lcking flip-up and armrest styles. NA w/ Mn Back. 183SG3 K0108 Plastic Regular 183SG4 K0108 Plastic Kids $ $ Armrest Size LOW Armrest Matrix fr Single Pst Classic Pad Transfer Tube Receiver Pad Length L Length D H Range Desk Full 8" 5 1/4" LOW LOW Receiver LOW LOW 10 3/4" t 15 3/4" 8 3/4" t 13 3/4" 9" t 13" 7 1/4" t 11 1/4" Cntur Pad Pad Length L H Range Desk Full 10" t 15" 8 1/4" t 12 1/2" 8 1/2" t 12 1/2" 6 3/4" t 10 3/4" 10 1/4" 10 1/2" 14" 14 1/4" 9. KEY OPTIONS AND ACCESSIES Anti Tips Included with vent tray ptin. Nt rdered as separate line item. 183AT1 E0971 Anti Tips (Pair) 183A A A A A120 E0978 E0978 E0978 E0978 K0108 Spke Guards Nt available with 12" and 16" mag wheels r prjectin handrims. 183A24 183A23 K0065 K0065 Clear Black NA w/ prjectin handrims Wheelchair Tray Table Only available if armrests are included. NA with JAY Arm Trughs. 183A30 E0950 Small (13"-14") $ A31 E0950 Medium (15"-17") $ A32 E0950 Large (18"-20") $ A33 E0950 X-Large (21"-22") $ Utility hk has weight a limit f 15 lbs. 183LF12 183LF13 E1029 E1029 Psitining Belt 2" Dual Pull Squeeze Pad w/clamp 1.5" Aut Buckle Universal w/clamp 2" Aircraft Buckle w/clamps 2" Aircraft Buckle Pad w/clamp Psitining Belt Clamps Only Vent Tray - Back Cane Munt Dvetail Vertical Frame Munted Hardware fr LTV Ventilatrs includes 1 utility hk Dvetail Vertical Frame Munted Hardware fr Trilgy Ventilatrs includes 1 utility hk $ $85.00 $70.00 $ $ $50.00 $ $ $ $ JY01 183JY02 183JY03 183JY04 183JY05 183JZ01 183JZ02 183JZ03 183JZ04 183JA01 183JA02 183JA03 183JA04 JAY Anterir Thracic Supprt Style Classic Dynamic Classic Structure Cntur Dynamic Cntur Structure Center Opening with Buckle Size Small Medium Large X-Large JAY Padded Trunk Strap Padded Trunk Strap - Small Padded Trunk Strap - Medium Padded Trunk Strap - Large Padded Trunk Strap - XL Miscellaneus Accessries 183A1 Black Utility Backpack $ A8 Black Seat Puch $ A54 Extra Leg Strap Black $ A82 183A A701 Caddy Only available w/ extentin tube munted ftrests O2 Hlder NA w/ Height Adj Strller E2208 Handles. NA w/ Reclining Backrest, Mn Back K0105 IV Ple NA w/ Mn Back Canpy (SunShade) Need 2" back pst clearance t munt canpy hardware. May require next height based n seating. Sme interferance may ccur with sme height cnfiguratins. NA with Mn Back. $45.00 $ $ A06 K0108 Canpy (Sunshade) 10 "- 14" wide $ A07 K0108 Canpy (Sunshade) 15" - 20" wide $ Specificatins are subject t change withut ntice. Cpyright 2011 Sunrise Medical (US) LLC. Quickie IRIS, MK REV H Page 7

8 a Optin # HCPCS Definitin a Optin # HCPCS 10. COL Definitin Standard Frame Clr Custm Frame Clr 183C140 Aztec Gld 183C126 Glw 183C112 Desert Camuflage $ C2 Black 183C144 Green Apple 183C43 Mssy Oak Camuflage $ C141 Black Cherry 183C147 Ht Sparkle Pink 183C42 Stars & Stripes $ C10 Black Opal 183C148 Mauve Pink Zebra (Chse abve base clr) Std 183C38 Blue Opal 183C103 Rtbeer 183C108 with White unless abve base paint is $ C36 Candy Blue 183C114 Sparkle Silver chsen NA w/ Black 183C14 Candy Purple 183C145 Sunrise Orange 183C35 Candy Red 183C113 Titanium 183C142 Electric Blue 183C8 Yellw 183C143 Evergreen Matte Frame Clr 183C116 Matte Black 183C151 Matte Black Cherry 183C150 Matte Electric Blue 183C149 Matte Evergreen 183C152 Matte Purple 11. APPENDIX Lwer Leg Length Matrix Frnt seat height must be at least 2" taller than lwer leg length n all swing in/ut hangers. Frnt seat height must be at least 2" taller than maximum lwer leg length n all frnt munt hangers. Specificatins are subject t change withut ntice. Cpyright 2011 Sunrise Medical (US) LLC. Quickie IRIS, MK REV H Page 8

9 a Optin # HCPCS Definitin a Optin # HCPCS Definitin J3PAMTT12FS E " Wide J3 Back w/ 15" Shell Height $ J3PLMTT12FS E " Wide J3 Back w/ 15" Shell Height $ J3PAMTT14FS E " Wide J3 Back w/ 15" Shell Height $ J3PLMTT14FS E " Wide J3 Back w/ 15" Shell Height $ J3PAMTT16FS E " Wide J3 Back w/ 15" Shell Height $ J3PLMTT16FS E " Wide J3 Back w/ 15" Shell Height $ J3PAMTT18FS E " Wide J3 Back w/ 15" Shell Height $ J3PLMTT18FS E " Wide J3 Back w/ 15" Shell Height $ J3PAMTT20FS E " Wide J3 Back w/ 15" Shell Height $ J3PLMTT20FS E " Wide J3 Back w/ 15" Shell Height $ J3PAUTS12FS E " Wide J3 Back w/ 16.5" Shell Height $ J3PLUTS12FS E " Wide J3 Back w/ 16.5" Shell Height $ J3PAUTS14FS E " Wide J3 Back w/ 16.5" Shell Height $ J3PLUTS14FS E " Wide J3 Back w/ 16.5" Shell Height $ J3PAUTS16FS E " Wide J3 Back w/ 16.5" Shell Height $ J3PLUTS16FS E " Wide J3 Back w/ 16.5" Shell Height $ J3PAUTS18FS E " Wide J3 Back w/ 16.5" Shell Height $ J3PLUTS18FS E " Wide J3 Back w/ 16.5" Shell Height $ J3PAUTS20FS E " Wide J3 Back w/ 16.5" Shell Height $ J3PLUTS20FS E " Wide J3 Back w/ 16.5" Shell Height $ J3PAUTM14FS E " Wide J3 Back w/ 18" Shell Height $ J3PLUTM14FS E " Wide J3 Back w/ 18" Shell Height $ J3PAUTM16FS E " Wide J3 Back w/ 18" Shell Height $ J3PLUTM16FS E " Wide J3 Back w/ 18" Shell Height $ J3PAUTM18FS E " Wide J3 Back w/ 18" Shell Height $ J3PLUTM18FS E " Wide J3 Back w/ 18" Shell Height $ J3PAUTM20FS E " Wide J3 Back w/ 18" Shell Height $ J3PLUTM20FS E " Wide J3 Back w/ 18" Shell Height $ J3PAUTM22FS E " Wide J3 Back w/ 18" Shell Height $ J3PLUTT14FS E " Wide J3 Back w/ 19.5" Shell Height $ J3PAUTT14FS E " Wide J3 Back w/ 19.5" Shell Height $ J3PLUTT16FS E " Wide J3 Back w/ 19.5" Shell Height $ J3PAUTT16FS E " Wide J3 Back w/ 19.5" Shell Height $ J3PLUTT18FS E " Wide J3 Back w/ 19.5" Shell Height $ J3PAUTT18FS E " Wide J3 Back w/ 19.5" Shell Height $ J3PLUTT20FS E " Wide J3 Back w/ 19.5" Shell Height $ SH Shells- 4 Pint Standard Hardware J3PLSHS14FS E " Wide J3 Back w/ 21" Shell Height $ J3PASHS14FS E " Wide J3 Back w/ 21" Shell Height $ J3PLSHS16FS E " Wide J3 Back w/ 21" Shell Height $ J3PASHS16FS E " Wide J3 Back w/ 21" Shell Height $ J3PLSHS18FS E " Wide J3 Back w/ 21" Shell Height $ J3PASHS18FS E " Wide J3 Back w/ 21" Shell Height $ J3PLSHS20FS E " Wide J3 Back w/ 21" Shell Height $ J3PASHS20FS E " Wide J3 Back w/ 21" Shell Height $ J3PLSHM16FS E " Wide J3 Back w/ 22.5" Shell Height $ J3PASHS22FS E " Wide J3 Back w/ 21" Shell Height $ J3PLSHM18FS E " Wide J3 Back w/ 22.5" Shell Height $ J3PASHM16FS E " Wide J3 Back w/ 22.5" Shell Height $ J3PLSHM20FS E " Wide J3 Back w/ 22.5" Shell Height $ J3PASHM18FS E " Wide J3 Back w/ 22.5" Shell Height $ J3PLSHT18FS E " Wide J3 Back w/ 24" Shell Height $ J3PASHM20FS E " Wide J3 Back w/ 22.5" Shell Height $ J3PLSHT20FS E " Wide J3 Back w/ 24" Shell Height $ J3PDMTT14FS E " Wide J3 Back w/ 15" Shell Height $ J3PDUTM18FS E " Wide J3 Back w/ 18" Shell Height $ J3PDMTT16FS E " Wide J3 Back w/ 15" Shell Height $ J3PDUTM20FS E " Wide J3 Back w/ 18" Shell Height $ J3PDMTT20FS E " Wide J3 Back w/ 15" Shell Height $ J3PDSHS14FS E " Wide J3 Back w/ 21" Shell Height $ UT Shells- 4 Pint Standard Hardware J3PDSHS16FS E " Wide J3 Back w/ 21" Shell Height $ JAY J3 Back PA (2.2" Cntur Depth) MT Shells- 4 Pint Standard Hardware UT Shells- 4 Pint Standard Hardware JAY Signature Series Backrest and Accessries Nte: Nt all sizes and cnfiguratins shwn belw, fr full ffering visit When rdering mark the part number desired and it will be added t the rder as a separate line item. JAY BACKREST JAY J3 Back PL (3" Cntur Depth) MT Shells- 4 Pint Standard Hardware UT Shells- 4 Pint Standard Hardware J3PAUTT20FS E " Wide J3 Back w/ 19.5" Shell Height $ SH Shells- 4 Pint Standard Hardware J3PASHT18FS E " Wide J3 Back w/ 24" Shell Height $ J3PASHT20FS E " Wide J3 Back w/ 24" Shell Height $ JAY J3 Back PD (6" Cntur Depth) MT Shells- 4 Pint Standard Hardware UT Shells- 4 Pint Standard Hardware Cntinued J3PDMTT18FS E " Wide J3 Back w/ 15" Shell Height $ SH Shells- 4 Pint Standard Hardware J3PDUTM14FS E " Wide J3 Back w/ 18" Shell Height $ J3PDSHS18FS E " Wide J3 Back w/ 21" Shell Height $ J3PDUTM16FS E " Wide J3 Back w/ 18" Shell Height $ J3PDSHS20FS E " Wide J3 Back w/ 21" Shell Height $ JAY J3 Back Headrest AXYS Munt and Pad LINX Munt and Pad J3HEDX8 E0955/E1028 AXYS Headrest with 8" Plush Pad $ J3HEDL8 E0955/E1028 LINX Headrest with 8" Plush Pad $ J3HEDX10 E0955/E1028 AXYS Headrest with 10" Plush Pad $ J3HEDL10 E0955/E1028 LINX Headrest with 10" Plush Pad $ J3HEDX14 E0955/E1028 AXYS Headrest with 14" Plush Pad $ J3HEDL14 E0955/E1028 LINX Headrest with 14" Plush Pad $ J3HEDXAAPN E0955/E1028 AXYS with Adj-a-Plush Narrw Pad $ J3HEDLAAPN E0955/E1028 LINX with Adj-a-Plush Narrw Pad $ J3HEDXAAPS E0955/E1028 AXYS with Adj-a-Plush Std Pad $ J3HEDLAAPS E0955/E1028 LINX with Adj-a-Plush Std Pad $ JAY J3 Back Laterals Swing Away Laterals With Pad - Pair J3LAT4X4SA E0956/E1028 SwingAway Lat with 4"x4" Pad (PR) $ J3LAT6X4SA E0956/E1028 SwingAway Lat with 6"x4" Pad (PR) J3LAT4X5SA E0956/E1028 SwingAway Lat with 4"x5" Pad (PR) $ J3LAT6X5SA E0956/E1028 SwingAway Lat with 6"x5" Pad (PR) J3LAT4X6SA E0956/E1028 SwingAway Lat with 4"x6" Pad (PR) $ J3LAT6X6SA E0956/E1028 $ $ SwingAway Lat with 6"x6" Pad (PR) $ Specificatins are subject t change withut ntice. Cpyright 2011 Sunrise Medical (US) LLC. Quickie IRIS, MK REV H Page 9

10 a Optin # HCPCS Definitin a Optin # HCPCS JAY Fusin Cushin Definitin JAY Signature Series Cushins Nte: Nt all sizes and cnfiguratins shwn belw, fr full ffering visit When rdering mark the part number desired and it will be added t the rder as a separate line item. JAY CUSHIONS JAY J2 Cushin JFUSION1416 E2622 JAY Fusin 14" x 16" $ MJ E2622 JAY J2 14" x 16" $ JFUSION1616 E2622 JAY Fusin 16" x 16" $ MJ E2622 JAY J2 15.5" x 16" $ JFUSION1618 E2622 JAY Fusin 16" x 18" $ MJ E2622 JAY J2 15.5" x 18" $ JFUSION1620 E2622 JAY Fusin 16" x 20" $ MJ E2622 JAY J2 15.5" x 20" $ JFUSION1717 E2622 JAY Fusin 17" x 17" $ MJ E2622 JAY J2 17" x 17" $ JFUSION1816 E2622 JAY Fusin 18" x 16" $ MJ E2622 JAY J2 18" x 16" $ JFUSION1818 E2622 JAY Fusin 18" x 18" $ E2622 JAY J2 18" x 18" $ JFUSION1820 E2622 JAY Fusin 18" x 20" $ MJ E2622 JFUSION2018 E2622 JAY Fusin 20" x 18" $ MJ E2622 JFUSION2020 E2622 JAY Fusin 20" x 20" $ JFUSION2220 E2623 JAY Fusin 22" x 20" $ JAY Fusin Cushin w/ ROHO Single Valve Air Insert JFUSION1416AS E2622 JAY Fusin 14" x 16" $ E2622 JAY J2 Deep Cntur 14" x 16" $ JFUSION1616AS E2622 JAY Fusin 16" x 16" $ E2622 JAY J2 Deep Cntur 16" x 16" $ JFUSION1618AS E2622 JAY Fusin 16" x 18" $ E2622 JAY J2 Deep Cntur 16" x 18" $ JFUSION1620AS E2622 JAY Fusin 16" x 20" $ E2622 JAY J2 Deep Cntur 16" x 20" $ JFUSION1717AS E2622 JAY Fusin 17" x 17" $ E2622 JAY J2 Deep Cntur 17" x 17" $ JFUSION1816AS E2622 JAY Fusin 18" x 16" $ E2622 JAY J2 Deep Cntur 18" x 16" $ JFUSION1818AS E2622 JAY Fusin 18" x 18" $ E2622 JAY J2 Deep Cntur 18" x 18" $ JFUSION1820AS E2622 JAY Fusin 18" x 20" $ E2622 JAY J2 Deep Cntur 18" x 20" $ JFUSION2018AS E2622 JAY Fusin 20" x 18" $ E2622 JAY J2 Deep Cntur 20" x 18" $ JFUSION2020AS E2622 JAY Fusin 20" x 20" $ MJ E2622 JAY J2 Deep Cntur 20" x 20" $ JFUSION2220AS E2623 JAY Fusin 22" x 20" $ E2623 JAY J2 Deep Cntur 22" x 18" $ JAY Fusin Cushin w/ ROHO Dual Valve Air Insert JFUSION1416AD E2622 JAY Fusin 14" x 16" $ JX21416 E2622 JAY X2 14" x 16" $ JFUSION1616AD E2622 JAY Fusin 16" x 16" $ JX21616 E2622 JAY X2 16" x 16" $ JFUSION1618AD E2622 JAY Fusin 16" x 18" $ JX21618 E2622 JAY X2 16" x 18" $ JFUSION1620AD E2622 JAY Fusin 16" x 20" $ JX21620 E2622 JAY X2 16" x 20" $ JFUSION1717AD E2622 JAY Fusin 17" x 17" $ JX21717 E2622 JAY X2 17" x 17" $ JFUSION1816AD E2622 JAY Fusin 18" x 16" $ JX21816 E2622 JAY X2 18" x 16" $ JFUSION1818AD E2622 JAY Fusin 18" x 18" $ JX21818 E2622 JAY X2 18" x 18" $ JFUSION1820AD E2622 JAY Fusin 18" x 20" $ JX21820 E2622 JAY X2 18" x 20" $ JFUSION2018AD E2622 JAY Fusin 20" x 18" $ JX22020 E2622 JAY X2 20" x 20" $ JFUSION2020AD E2622 JAY Fusin 20" x 20" $ JFUSION2220AD E2623 JAY Fusin 22" x 20" $ JAY Unin Cushin JU1416 E2607 JAY UNION 14" x 16" $ JION1416 E2607 JAY ION 14" x 16" $ JU1616 E2607 JAY UNION 16" x 16" $ JION1616 E2607 JAY ION 16" x 16" $ JU1618 E2607 JAY UNION 16" x 18" $ JION1618 E2607 JAY ION 16" x 18" $ JU1620 E2607 JAY UNION 16" x 20" $ JION1620 E2607 JAY ION 16" x 20" $ JU1717 E2607 JAY UNION 17" x 17" $ JION1717 E2607 JAY ION 17" x 17" $ JU1816 E2607 JAY UNION 18" x 16" $ JION1816 E2607 JAY ION 18" x 16" $ JU1818 E2607 JAY UNION 18" x 18" $ JION1818 E2607 JAY ION 18" x 18" $ JU1820 E2607 JAY UNION 18" x 20" $ JION1820 E2607 JAY ION 18" x 20" $ JU2018 E2607 JAY UNION 20" x 18" $ JION2018 E2607 JAY ION 20" x 18" $ JU2020 E2607 JAY UNION 20" x 20" $ JION2020 E2607 JAY ION 20" x 20" $ JU2220 E2608 JAY UNION 22" x 20" $ JION2220 E2608 JAY ION 22" x 20" $ JAY Unin Reduced Prfile Cushin JU1416RP E2607 JAY Unin RP 14" x 16" $ JU1816RP E2607 JAY Unin RP 18" x 16" $ JU1616RP E2607 JAY Unin RP 16" x 16" $ JU1818RP E2607 JAY Unin RP 18" x 18" $ JU1618RP E2607 JAY Unin RP 16" x 18" $ JU1820RP E2607 JAY Unin RP 18" x 20" $ JU1620RP E2607 JAY Unin RP 16" x 20" $ JU2018RP E2607 JU1717RP E2607 JAY Unin RP 17" x 17" $ JU2020RP E2607 JAY Unin RP 20" x 20" $ MJ E2622 JAY J2 Deep Cntur Cushin JAY X2 Cushin JAY In Cushin JAY J2 18" x 20" $ JAY J2 20" x 18" $ JAY J2 20" x 20" $ JAY Unin RP 20" x 18" $ Specificatins are subject t change withut ntice. Cpyright 2011 Sunrise Medical (US) LLC. Quickie IRIS, MK REV H Page 10