Quickie 7 R Octber 2015 EIR11 Mark Fr: Submitting fr: Qute Order Date: Dealer Acct #: PO#: Dealer: Dealer Cntact: ADDITIONAL SHIPPING INFORMATION Ship T: Dealer Address: Attentin: Dealer City: ST: ZIP: Address: Dealer Phne: ( ) Fax: ( ) Address: Cnfirmatin Email: Ship T City: ST: ZIP: Cnfirm Via: Fax Email Ship T Phne: ( ) Fax: ( ) a Optin # 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. HCPCS Definitin Price a 1. FRAME Optin # HCPCS Definitin Price 132WM88 K0005 Base Mdel Quickie 7 R - Adjustable (265 lbs) Use E1235 fr sizes r less Perfrmance Package (N substitutins, discunt given n separate line) 132QD01 Single Sided Frk Ultra Lightweight Wheel Schwalbe Marathn Plus Evlutin Cmpact Wheel Lck Retail Value $625.00 Package Price $535.00 Ultra Lite Package (N substitutins, discunt given n separate line) 132QD02 Ultra Lite Seat Sling Ultra Lightweight Wheel Schwalbe Speed Run Tire Cmpact Wheel Lck Retail Value $600.00 Package Price $510.00 Frame Angle See FIGURE 1 Measure frm frnt frame t flr. 132FA1 132FA8 75 80 132FA2 85 $1,750.00 See FIGURE 2 Frame Inset is the distance frm the utside f the seat tube t the utside f the ftrest. 132FF1 132FF2 0" 1" (NA w/ 12" wide) 132FF3 2" (NA with 12" & 13" wide) Frame Style See FIGURE 3 Measurement fr set up. 132FS9 Standard 132FS34 Classic * Standard Frame - Seat Sling t frnt frame bend angle is 1.5" shrter than the classic psitin. Classic Frame - Traditinal seat sling t frnt frame bend angle dimensins. Frnt f back cane pst t frnt edge f seat sling will remain the same fr bth Standard and Classic. Frame - Direct Munt Wheel Lck (Optinal) N munting clamp hardware. Only available with Cmpact Wheel Lck and 0 & 3 Camber. Nt available with muntain tires r rear suspensin. 132WH13 Direct Munt Wheel Lck 132TO45 Frame Inset Per Side Transit Transit System $315.00 Figure 1 Figure 2 Figure 3 Custmer Service: 800-236-4215 Fax: 602-279-0952 Email: rders@suthwestmedical.cm Frm mdified fr purchases made thrugh www.sutwhestmedical.cm Page 1
2. SIZE / SEATING Depth Adjustable Backrest (Optinal) See Figure 4 Depth Adjust Backrest extends the frame rear f the seat sling, select a factry setting. 132DP02 132DP03 132DP04 0 Backrest at standard psitin, field adjustable t -1" r -2" Figure 5 Figure 6 $165.00-1 Backrest -1" ffset, field adjustable t flush r -2" $165.00-2 Backrest -2" ffset, field adjustable t flush r -1" $165.00 Figure 4 Seating Systems Standard Seat Sling 132OP01 132OP02 Available t 18" Widths and Depths. Ultra Seat Sling will be ~1/4" less than requested seat height value. 132OP04 Omit Seat Sling 132CU1 Ultra Seat Sling Seat Width See FIGURE 5 Measure frm utside f seat tube t the utside f ppsite seat tube. 132S3 132S4 132S5 132S6 132S7 12" 13" 15" 16" 132S8 132S9 132S10 132S48 17" 18" 19" 20" (E2201) $500.00 Seat Depth See FIGURE 6 Measure frm frnt f back pst t frnt edge f seat sling. Seat sling is 1" shrter than depth rdered, but actual seat depth will remain the same as rdered. 132SD5 132SD6 132SD7 132SD8 132SD9 12" 13" 15" 16" 132SD10 132SD11 132SD12 132SD13 17" 18" 19" Cushin K0669 2" Cushin $120.00 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 132JC20 Cushin Name r Part # Price List Width: Depth: 20" (E2203) $550.00 3. CASTERS / SEAT HEIGHT Frnt Seat Height See FIGURE 7 Measure frm the frnt f the seat rail t the flr. 132SH14 16.0" 132SH20 132SH15 16.5" 132SH21 132SH16 17.0" 132SH23 132SH17 17.5" 132SH24 132SH18 18.0" 132SH26 132SH27 18.5" 19.0" 19.5" 20.0" 20.5" 21.0" Figure 7 132CF74 132CF65 132CF69 132CF53 132CF54 132CF55 Caster Frk and Suspensin Carbtecture Frks Multiple Psitin Multiple Psitin Single Sided Frk E1015 Frg Legs 0 weight t 100 lbs. E1015 Frg Legs 101 lbs. weight t 190 lbs. E1015 Frg Legs 191 lbs. weight t 265 lbs. 132CW1 132CW3 132CW31 132CW72 132CW44 132CW64 132CW5 132CW51 132CW6 132CW65 132CW7 132CW66 132CW34 132CW33 132CW35 132CW68 Caster Wheels 3" Micr 4" Lw Prfile Plyurethane 4" Micr Lighted 4" x 1" Aluminum Ply 4" x 1.25 Semi Pneumatic 4" x 1.5" Aluminum Sft Rll 5" Lw Prfile Plyurethane 5" Micr Lighted 5" Sft Rll (Grey) -NA w/frg Legs 5" x 1" Aluminum Ply 5" x 1.5" Semi Pneumatic 5" x 1.5" Aluminum Sft Rll 6" Ply E2214 6" Pneumatic E2215 6" x 1.5" Semi Pneumatic 6" x 1.5" Aluminum Sft Rll $425.00 $425.00 $425.00 Custmer Service: 800-236-4215 Fax: 602-279-0952 Email: rders@suthwestmedical.cm Frm mdified fr purchases made thrugh www.sutwhestmedical.cm Page 2 $70.00 $55.00 $175.00 $110.00 $185.00
3. CASTERS / SEAT HEIGHT (CONT) Caster Husing Psitin Figure 8 See FIGURE 8 132LH01 132LH02 132LH03 1 Suggested fr 3" & 4" casters. Fr 2" Inset NA w/ setting 1 2 Suggested fr 5" & 6" casters. 3 NA w/ 6" casters 4. REAR WHEELS / SEAT HEIGHT Rear Seat Height Rear Wheel Tire RSH 13"-15.5" nly w/ 20" Rear Wheel. RSH 15"-15.5" Only w/ 20, 22 r 24" w/hp Clincher Rear Wheel. RSH 16"-16.5" NA w/ 24, 25 & 26" Rear Wheels and Rear Suspensin 132RH12 13.0" (NA w/ Rear Suspensin) 13.5" (NA w/ Rear Suspensin) 132RH13 132RH14 132RH15 132RH16 132RH17 132RH18 132RH19 132RH26 132RH20 132RH27 132RH21 132RH37 132RH22 14.0" 14.5" 15.0" 15.5" 16.0" 16.5" 17.0" 17.5" 18.0" 18.5" 19.0" 19.5" 20.0" 132RH11 ( NA w/ Rear Suspensin) 132RT1 132RT2 132RT3 E2218 Full Ply Tire 132RT38 E2218 SHOX Perfrmance Ply 132RT39 132RT21 132RT27 132RT12 132RT28 132CI1 132CI2 132CI4 0 3 6 (NA w/ 5 spk Mag wheel) Rear Wheel Ultra Lightweight nly available w/ Aluminum Handrim. Cntact Built 4 Me fr Spinergy clr ptins 20" Mag Wheel 5 Spke 132RW103 22" Mag Wheel 5 Spke 132RW104 24" Mag Wheel 5 Spke 132RW102 20" Lite Spke $200.00 132RW90 22" Lite Spke $200.00 132RW91 24" Lite Spke 132RW92 25" Lite Spke 132RW93 26" Lite Spke $80.00 132RW94 22" Ultra Lightweight Spke Wheel 132RW06 24" Ultra Lightweight Spke Wheel 132RW10 25" Ultra Lightweight Spke Wheel 132RW16 22" Spinergy SPOX Black Spkes 132RW28 24" Spinergy SPOX Black Spkes 132RW95 25" Spinergy SPOX Black Spkes 132RW96 26" Spinergy SPOX Black Spkes 132RW97 22" Spinergy LX Black Spkes 132RW32 24" Spinergy LX Black Spkes 132RW98 25" Spinergy LX Black Spkes 132RW99 26" Spinergy LX Black Spkes 132RW40 24" Muntain 132RW50 24" Tplin Carbn Red Spk Whl 132RW107 24" Tplin Carbn Yellw Spk Whl 132RW108 25" Tplin Carbn Red Spk Whl 132RW109 25" Tplin Carbn Yellw Spk Whl 132RW110 $80.00 High-Pressure Clincher Black Schwalbe Marathn Plus Evlutin Knbby V-TRAK by Kenda Muntain Only available in 24" Schwalbe Speed Run Tire Frnt t Rear Seat Height Matrix Camber Pneumatic Pneumatic Airless Insert E2213 12" Seat Depth 13", Seat Depth 2.5" Max Frnt t Rear Seat Hgt. 3.0" Max Frnt t Rear Seat Hgt. 15", 16" Seat Depth 17", 18" Seat Depth 19", 20" Seat Depth 3.5" Max Frnt t Rear Seat Hgt. 4.0" Max Frnt t Rear Seat Hgt. 4.5" Max Frnt t Rear Seat Hgt. Wheel Tire 5 Spke Mag Lite Spke,26,26 Full Ply SHOX Perfrmance Ply,25 High-Pressure Clinch Blk 22,24 Schwalbe Marathn,26 22, Knbby V Trak by Kenda 24 Schwalbe Speed Run 20"= 451 mm 22" = 501 mm 24" = 540 mm 25" = 559 Pneumatic Pneumatic w/ Airless Insert Ultra Lightweight Spinergy Tplin,26 24 26" = 590 24 Handrim Natural Fit Handrims nly available in 22", 24", & 25". Natural Fit w/ 5 spke MAG nly available in 24". See APPENDIX 11 fr matrix Aluminum Andized 132HR1 Plastic Cated NA w/ 25" & 26" 132HR4 Lite Spke Wheels Natural Fit - Standard Grip 132HR22 Natural Fit - Super Grip $410.00 132HR23 Natural Fit - N Thumb Grip 132HR25 Natural Fit LT - Standard Grip 132HR30 $410.00 132HR31 Natural Fit LT - Super Grip Natural Fit LT - N Thumb Grip 132HR32 The Surge - Oval w/griptin Strip 132HR26 The Surge LT - Oval w/griptin Strip $395.00 132HR27 Q-Grip Neprene Cated $315.00 132HR28 Spinergy Flex Rim Only available n 132HR24 $525.00 Spinergy LX wheels 24" & 25" Omit Handrim 132HR7 NA w/ Ultra Lightweight Wheels Custmer Service: 800-236-4215 Fax: 602-279-0952 Email: rders@suthwestmedical.cm Frm mdified fr purchases made thrugh www.sutwhestmedical.cm Page 3
4. REAR WHEELS / SEAT HEIGHT (CONT) 132AX1 132AX13 Axle Quick Release Steel Quad Quick Release Steel Only available with Muntain Whls Axle Plate Adjustable COG (1"-4") Adjustable Extended COG (0"-3") Center f Gravity Preset Measure frm frnt f back pst t the center f rear axle. 0" 132CC12.5" 132CC1 1.0" 132CC2 1.5" 132CC3 2.0" 132CC4 2.5" 132CC5 3.0" 132CC6 3.5" 132CC7 4.0" 132CC8 Rear Suspensin (Optinal) 4-Link Rear Suspensin COG (0"-3") Single Pst nly available up t 2" COG. Plastic Side Guards nly available up t 2.5" COG. $595.00 132SV08 Weight frm 0 lbs t 175 lbs $595.00 132SV09 Weight frm 176 lbs. t 265 lbs 5. WHEEL LOCKS Wheel Lck Nt all wheel lcks available in all seat depths, wheel size, r COG 132WL1 High Munt Push 132WL2 High Munt Pull 132WL45 Erg Scissr 132WL30 Cmpact 132WL10 Omit Wheel Lck Wheel Lck Optins D Nt Munt 132WL12 Extensin Handle Ext. handles nly available with high munt push r pull wheel lcks E0961 Extensin Handle (Pair) 132EH7 $65.00 6. FOOTREST OPTIONS 132F229 132F274 132F276 132F325 132F51 Ftrest Aluminum Tubular Aluminum Tubular w/ Snap On Cver K0040 Angle Adjustable Flip Back Angle Adjustable FB Carbn Fiber K0040 Platfrm Ftrest $30.00 $185.00 $185.00 132F111 Ultra Lite Platfrm Ftrest K0040 NA w/ wide and 2" inset, NA w/ 19-20 $115.00 wide w/ 0" inset 132F323 Platfrm Carbn Fiber ftrest Nt available n 19"-20" W $135.00 Adaptive Platfrm Spacer NA with Aluminum Tubular r Ultra Lite Platfrm. 132AD1 Adaptive Platfrm 2" Spacer 132AD2 Adaptive Platfrm 4" Spacer 132AD3 Adaptive Platfrm 6" Spacer 132DI08 132DI03 132DI04 132DI05 132DI07 132DI02 132DI06 Ftrest Optins High Munt Ext Tubes (NA w/ Tubular ftrest) K0038 Leg Strap K0038 Extra Leg Strap Gel Hanger Cver Neprene Impact Guards Wear Pads Psitin Plates NA fr Tubular Ftrest K0037 Custmer Service: 800-236-4215 Fax: 602-279-0952 Email: rders@suthwestmedical.cm Frm mdified fr purchases made thrugh www.sutwhestmedical.cm Page 4 $55.00 $35.00 $35.00 $105.00
7. BACKREST Back Type Freestyle Backrest nt available n Active Rigid chairs. See ptin 3 fr details 132BT3 132BT96 132BT121 132BT122 Nn-Flding Angle Adjustable Flding w/ Duble Lck Dwn Angle Adj Freestyle Backrest Nn- flding Freestyle Backrest Flding Chse Optin 1 r 2 1. Aluminum Height Adjustable Backrest 10 "- Back Height 10 11 12 12 "- 16" Back Height 12 13 14 14 "- 18" Back Height 14 15 16 16 "- 20" Back Height 16 17 18 2. Ultra Lightweight Aluminum Fixed Backrest 132B110 132B127 132B111 132B137 132QT01 132QT02 132PH6 132PH5 132PH2 Push Handles Integral Push Handles Fld Dwn Push Handles NA w/ 10" adj height & 8"-10" fixed height NA w/ standard uphlstery Omit Push Handles 132BU1 Backrest Uphlstery Standard Uphlstery 132BU70 E2611 132BU71 E2611 132BU14 14 15 16 17 18 19 20 Twel Bar Standard Style - 4" Offset Lw Prfile - 2" Offset Limited w/slid Backs, Nt suggested with 19" & 20" wide 13 Backrest Tensin Adj Ballistic Nyln *Reference 186BU70 fr billing Backrest Tensin Adj 3DX Vented *Reference 186BU71 fr billing Omit Back Uphlstery $315.00 132JB01 Backrest Optins Telescping Push Handlles have Duble "D" tubing t eliminate rtatin. Narrw Backrest Inset Backcanes 1" $330.00 -$15.00 JAY J3 Back Military Service Patches Only available n tensin adjustable uphlstery and when rdered separate thrugh JAY J3 Back OF 132VU1 US Marines Patch 132VU2 US Army Patch 132VU3 US Navy Patch 132VU4 US Air Frce Patch 132VU12 Cast Guard Patch 132VU5 Purple Heart Patch 132VU8 Purple Heart with Marines Patch 132VU9 Purple Heart with Army Patch 132VU10 Purple Heart with Navy Patch 132VU11 Purple Heart with Air Frce Patch 132VU13 Purple Heart with Cast Guard Patch J3 Back T rder a J3 Back please select Omit Back Uphlstery. See J3 Back Order Frm fr Part #'s. NA w/freestyleback Select back height. 8", 9", r 10" nly available with mit push handles. 17", 18", r 19" nly available with fld dwn push handles 132BB21 8" 132BB17 132BB20 9" 132BB18 15" 132BB13 10" 132BB19 16" 132BB14 11" 132BB10 17" 132BB15 12" 132BB11 18" 132BB16 13" 132BB12 19" Price List 132OD5 132A192 132A195 narrwer than selected seat width. NA with 12" Wide. NA w/ Aluminum r Carbn Side Guards Telescping Push Handles Range f 13-19" frm sling t handle Telescping Push Handles - Tall (25" frm seat t push handle) $80.00 $215.00 $215.00 Freestyle Backrest Optin 3 Accessries such as head supprts & lateral supprts are nt available with Freestyle backrest. The arch back cmes standard with a small lumbar psitining cmpnent NA w/ any Side Guard, chair Seat depth wil be reduced by 1" with backrest. Backrest Type 132JB06 JAY J3 Back LT Aluminum mdel $535.00 132JB07 JAY J3 Back LT Carbn Fiber mdel $895.00 Backrest Width Backrest Width 16" Backrest Width 18" Backrest Width 20" Backrest Width 132JQ01 132JQ02 132JQ03 132JQ04 Backrest Height Medium size backrest nt available in Carbn Fiber. 132QF04 132QF05 132QF06 Small 6.5" shell height Medium 8" shell height Tall 9.5" shell height Backrest Clr Nt applicable with carbn fiber back 132GZ01 Black 132GZ02 Matching Frame- Standard Clrs 132GZ03 Matching Frame- Custm Clr Height Ranges Dim "A" Dim "B" Small Medium Tall 12.0" - 14.5" 12.0" - 16.0" 12.0" - 17.5" 3.0" - 5.5" 1.5" - 5.5" 0.5" - 5.5" Custmer Service: 800-236-4215 Fax: 602-279-0952 Email: rders@suthwestmedical.cm Frm mdified fr purchases made thrugh www.sutwhestmedical.cm Page 5
8. ARMREST / SIDEGUARDS Armrest - Padded Swing Away Side Guards Sme limitatins when used with the Angle Adjustable Back in the rear mst setting Please select a setting, will default t 11" if n selectin is made 132AA18 E0973 Padded Swing-Away STD (9" t ) 9" 10" 11" 12" 13" 132AA11 Armrest - Height Adjustable Single Pst Height Adjustable - Std E0973 132AA29 E0973 132AM23 132AM21 132AM24 132AM22 Range 8" - 13". Adjust in 1" increments Single Pst Height Adjustable - Lw Range 6.5" - 10.5". Adjust in 1" increments Armpad - Fr Height Adjustable Desk Length (10") Classic Desk Length (10") Cntur Full Length () Classic Full Length () Cntur $210.00 Increases verall width f chair. Sme interferance may exist w/ padded SA arms at lwest settings Nt available w/height Adjustable Arms 132SG33 K0108 Plastic Standard 132SG29 K0108 Plastic Lw Aluminum NA w/high Push r Pull 132SG35 K0108 $285.00 132SG36 K0108 Aluminum w/ Fender NA w/ High Push $285.00 132SG12 K0108 132SG41 K0108 Wheel Lcks r Pull Wheel Lcks Carbn Fiber NA w/ High Push r Pull Wheel Lcks Carbn Fiber Lng w/lg Fender NA w/high Push r Pull Wheel Lcks $235.00 $245.00 $450.00 $495.00 Side Guard - Clr Optin Available with Aluminum r Aluminum with Fender. Nt applicable t carbn fiber ptins 132GE01 Black 132GE02 Matching Frame- Standard Clrs 132GE03 Matching Frame- Custm Clr 9. KEY OPTIONS AND ACCESSORIES 132AT37 132A1 132A2 1321A01 Anti Tips E0971 Anti Tips (Pair) Additinal Pack Accessries Backpack - Adult Backpack - Kids Seat Puch Black $140.00 Spke Guards Only available with Lite spke 1324A01 K0065 Quickie Black Spke Guard 1324A02 K0065 Quickie Clear Spke Guard $55.00 $45.00 132A824 Psitining Belt E0978 Belt 2" Aircraft Buckle 132A825 E0978 Belt 2" Aircraft Buckle Padded $120.00 132A826 E0978 Belt 1.5" Aut Buckle Universal $70.00 132A804 K0108 Psitining Belt Clamps Only $110.00 132A2100 1328A21 132NP01 Miscellaneus E2207 Crutch Hlder Tl Kit Gel Swing Away Pad $115.00 $115.00 $45.00 $105.00 10. COLOR 132C140 132C118 132C2 132C141 132C10 132C38 132C36 132C14 132C35 132C142 132C143 132C44 132C126 132C144 132C147 132C148 132C103 132C114 132C145 132C113 132C8 Standard Frame Clr Aztec Gld Bead Blast Black (Nt avail as base w/zebra) Black Cherry Black Opal Blue Opal Candy Blue Candy Purple Candy Red Electric Blue Evergreen Glssy White - Limited Editin Glw Green Apple Ht Sparkle Pink Mauve Pink Rtbeer Sparkle Silver Sunrise Orange Titanium Clr Paint Yellw Matte Frame Clrs Matte Black Matte Black Cherry Matte Electric Blue Matte Evergreen Matte Purple 132C116 132C151 132C150 132C149 132C152 132C112 132C43 132C42 Custm Frame Clr Desert Camuflage Mssy Oak Camuflage Stars & Stripes Zebra (Chse abve base clr) Std with 132C108 White unless abve base paint is chsen NA w/ Blk, Matte Black, Blk Opal, Titanium r Bead Blast) Custmer Service: 800-236-4215 Fax: 602-279-0952 Email: rders@suthwestmedical.cm Frm mdified fr purchases made thrugh www.sutwhestmedical.cm Page 6
10. COLOR (CONT) Andized Clr Package Frks, Backcane Bracket, Rear Axle Clamp,and Freestyle munting bracket (if selected). NA w/ Frg Legs & Carbtecture frks. 132EB07 132EB08 132EB13 132EB09 132EB10 132EB11 132EB12 Black Blue Gld Lime Green Purple Red Ti Grey Frame Graphics Graphic designs n frnt frame tubes. NA with transit & Matte Black Cherry. NA w shrt height frames 1328A24 Blm 1328A25 Dragn 1328A26 1328A27 Ghst Flames Retr Squares 1328A28 Tribal Blm design Dragn design Ghst Flames design Retr Squares design Tribal design 11. APPENDIX Handrim & WheelMatrix Wheels Handrims 5 Spke Mag Lite Spke Ultra Lightweight Spinergy Muntain Aluminum Andized,26 22, 22,,26 24 Plastic Cat 22,24 N/A 22,,26 24 Natural Fit - Standard Grip 24 22,,26 N/A 22,,26 N/A Natural Fit - N Thumb Grip 24 22,,26 N/A 22,,26 N/A Tplin Natural Fit - Super Grip 24 22,,26 N/A 22,,26 N/A Natural Fit LT - Std Grip 24 22,,26 N/A 22,,26 Natural Fit LT - Super Grip 24 22,,26 N/A 22,,26 Natural Fit LT - N Thumb Grip 24 Surge - Oval w/griptin Strip N/A 22,,26 N/A 22,,26 N/A 24 22,,26 N/A 22,,26 N/A Surge LT - Oval w/griptin Strip 24 22,,26 N/A 22,,26 N/A Q Grip Neprene Cated N/A N/A N/A Spinergy Flex Rim N/A N/A N/A N/A Omit Handrim N/A N/A 22,,26 24 N/A N/A Custmer Service: 800-236-4215 Fax: 602-279-0952 Email: rders@suthwestmedical.cm Frm mdified fr purchases made thrugh www.sutwhestmedical.cm Page 7