Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Cnfirm Via: Mark Fr: ZIP: Zippie GS January 09 EIZGS SUBMITTING FOR: Qute Order Fax Email Ship T Phne: ( ) Fax: ( ) PO#: Ship T: Attentin: Address: Address: Ship T City: 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. ST: ZIP: a Optin # HCPCS Definitin Price a Optin # HCPCS Definitin Price 087WM70 E8 Flding Grwing Zippie GS Transit Included Includes True Fit Grwth $,00. FRAME All Zippie GS mdels grw in width and depth. 087WM7 E8 Flding Grwing Zippie GS $,50 Transit Optinal Includes True Fit Grwth 087WM7 E7 Rigid Grwing Zippie GS Transit Included Includes True Fit Grwth Nte: HCPCS Cdes shwn as submitted. Sme sizes fit ther HCPC cdes i.e. 5"-8" widths = K0005 $,00 087WM7 E7 Rigid Grwing Zippie GS Transit Optinal Includes True Fit Grwth Nte: HCPCS Cdes shwn as submitted. Sme sizes fit ther HCPC cdes i.e. 5"-8" widths = K0005 $,50 087FC Reverse Cnfiguratin ( w/ Swing-Away hangers nn-rem. in reverse cnfig.; lift ff hangers recmmended.) Frame Optins 087FC Standard Cnfiguratin Tie Dwn Requires: Slid Seat and Slid Back r, Grwing Seat Pan and JAY Fit r Cnventinal Back r, Grwing Seat Pan and Slid Back r, JAY Fit and/r Cnventinal Seat & Back 087TO9 Transit Optinal. Seating (Req. Selectin f Seat & Back) Frame Width. TRANSIT SYSTEM ( Fr use when Transit ptinal is chsen abve) $50 Height Adjustable Arms NA with 0"-" Frame Widths 087FL Shrt Frame 087BW Small Crss Brace 0" " " " " 0" " " 087FL9 Regular Frame 087BW5 Medium Crss Brace " " " 5" 6" " " " 087FL8 Lng Frame 087BW6 Large Crss Brace " 5" 6" 7" 8" " 5" 6" 087FL9 X-Lng Frame 087BW7 X-Large Crss Brace 6" 7" 8" 9" 0" (0" use HCPCS: E0) 6" 7" 8". SIZE/SEATING 087TO 087TO5 Transit Optinal w/ Seating Transit Omit Frame Depth and Back Pst Lcatin $50 Custmer Service: 800--000 Fax: 800-00-750 Email: rders@sunmed.cm Web: www.sunrisemedical.cm Page
. SIZE/SEATING CONT. Seats REFEREE ONLY 087ST55 087PN 087ST7 E Slid Seat (Req. Slid Back) ( w/ 0-, 9-0 inch frame depth r 7-8 inch frame width.) E Grwing Seat Pan Depth (Fig. ) Omit Seat $00 $00 Seat Depth Pan Size Depth Range Minimum Maximum Shrt 0-" 0" " Medium "-" /" 6 /" Lng 5"-7" JAY Cushins (Optinal) X-Lng 8"-0" /" 5 /" 8 /" 0 /" 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 087JC0 Name / Part # Price List Width: Depth: Depth Figure 7. - Frame Depth Grwth Range Matrix. CASTERS/SEAT HEIGHT Caster Wheel Caster Optins 087CW0 087CW " Micr Light Up " Micr Light Up $65 $70 087CS5 087CS9 /" Lnger Frk Stem Blt /" Lnger Frk Stem Blt 087CW5 087CW5 087CW7 E9 5" Micr Light Up 5" Lw-Prfile Plyurethane 5" x.5" Semi-Pneumatic 087CS 087CW8 K007 Caster Pin Lcks ( with 8" x " casters r Transit Opt.) Omit Caster, Wheels & Tires $95 087CW E5 6" Pneumatic 087CW 087CW5 087CW 087CW E9 E5 E5 6" Plyurethane 6" x.5" Semi-Pneumatic 8" Pneumatic 8" Plyurethane 087CW9 E9 8" x.5" Semi-Pneumatic 087CW6 8" x " Pneumatic $5 087CW7 8" x " Pneumatic w/airless Insert $5. REAR WHEELS/SEAT HEIGHT Axle Plate Axle 087AL7 E0958 One Arm Drive (Avail w/ 0","," Mag Rear Wheels & "-8" wide) $900 087AX6 One Arm Drive Axle (Only avail. w/one Arm Drive Optin) 087OA Standard Handrim 087AX Quick Release 087HM 087HM Right Left 087AX Quad Quick Release ( with Lite Spkes) $5 087OA Small Handrim 087HM Right 087HM Left Custmer Service: 800--000 Fax: 800-00-750 Email: rders@sunmed.cm Web: www.sunrisemedical.cm Page
087RW8 087RW 087RW 087RW8 087RW 087RW 087RW7 087RW75 087RW5 087RW5 Rear Wheel Size " Mag ( with handrims) 6" Mag ( with handrims). REAR WHEELS/SEAT HEIGHT CONT. Handrim 087HR Aluminum Andized 087HR Plastic Cated Omit 087HR7 ( with wheel/axle credit) 0" Mag " Mag Prjectins ( n Plastic Cated) " Mag *Only available with " wheels & with spke guards. 8" Spke 087HR8 8 Oblique 0" Lite Spke " Lite Spke " Lite Spke $00 Omit Rear Wheel & Axle - $5 Rear Wheel Tire 087RT Pneumatic 087RT 087RT E E Pneumatic Airless Insert Full Plyurethane ( w/ ", 6" and 8" rear wheels) 087RT Lw Plyurethane (Only available with " and " wheels ) 087RT6 E E High Pressure Clincher (Avail. w/ " spke wheels, with mag wheels) $95 5. WHEEL LOCK/HUB LOCK 087WL 087WL Wheel Lck with Hub Lcks High Munt Push High Munt Pull Hub Lck *Only available with " r 6" wheels. with One Arm Drive. 087LK0 " Hub Lck 087LK0 6" Hub Lck 087WL5 087WL0 Ft Lck (may limit flding width, in rev. cnfig.) Omit 087WL D Nt Munt 087EH E096 Extensin Handle 6" Pair Custmer Service: 800--000 Fax: 800-00-750 Email: rders@sunmed.cm Web: www.sunrisemedical.cm Page
Hanger Munted Ftrest (Ftplates Munt t Hanger Tubing) Hanger Type 087H89 087H90 70 Swing In/Out Frnt Munt 80 Swing In/Out Frnt Munt 087H6 90 Swing Away Frnt Munt 087H9 70 HD Frnt Munt Lift-Off 087H0 80 HD Frnt Munt Lift-Off 087H 90 HD Frnt Munt Lift-Off 087H E0990 90 Elevating ( 0"-" wide) $95 Extensins (may interfere with sme seat heights & casters) 087E " (nt munted) 087E " (nt munted) Ftplate 087F9 " Lw Ply Adult Angle Adj. 087F8 $85 (Available with 0"-8" widths) 087F6 087H85 087H86 087H6 087F 087F8 Kids Angle Adjustable ( w/7"-8" widths) Ftbard (Available with 0"-6" widths) Ext. Tube Munted Ftrest (Ftplate Munt t Ext. Tube) Hanger Type 60 Swing In/Out 70 Swing In/Out 80 Swing In/Out ( with 6" r 8" Casters) 087H K005 Articulating ( w/cmpsite ftplates r 0"-") 087H 087E 087E 087E5 087E6 087F 087F 087F5 E0990 Elevating ( w/ cmpsite r platfrm ftplates r < 6" width) Extensins Shrt (.5" - ") Med (" - 7") ( w/ ELR) Lng (7" - 9") High Munt Ftplate Cmpsite ( In 0", " r " width) Aluminum Angle Adjustable Kids Angle Adjustable ( w/7"-8" width) Aluminum (Only available with elevating leg rests "-8") Platfrm Flip-Up (Avail n 60 70 and 80 ext. munt hangers nly) 6. HANGER and FOOTRESTS $85 $90 $70 $95 $85 $85 Rear Wheel Size " 6" 8" 0" " $90 " Frnt Seat t Flr Height Guide (Reference Only) " " 5" CASTER SIZE 8"X" 8"X.5" Based n.5" seat angle. T achieve desired seat height see matrices n last page. 6" Custmer Service: 800--000 Fax: 800-00-750 Email: rders@sunmed.cm Web: www.sunrisemedical.cm Page
6. FOOTRESTS CONT. Ftrest Hanger Optins 087HL5 K008 Leg Strap $0 087IG Neprene Cvers (Avail. n 60 / 70 / 80 ext. munt hangers nly) $90 087A5 087H K008 Extra Single Leg Strap Omit Hanger $0 -$5 087HL E095 Heel Lps $0 087F7 Omit Ftplate & Ext. Tube -$5 087A0 E095 Te Lp (Only avail. w/ adult angle adjust. ftplates) $0 087HL 087HL6 Omit Heel Lp Omit Single Leg Strap 7. BACKREST/SEATING Back Height JAY Backs (Optinal) (Slid Back Depth = " Less Than Frame Depth) Ordering JAY backs n-chair, See the JAY Price List. Requires Part # 087B0 Shrt Slid Back " JAY Bundled Backrest 087B Med. Slid Back " 087JB0 Backrest Name r Part # Price List 087B Tall Slid Back 6" Width: Height: 087BU Omit Backrest Back Psts Fixed Height Height Adjustable 087BP9 Lw (9" Ht) Rigid Frame w/ Angle Adjust Push Handle 087BP0 Medium (" Ht) 087B0. (6"-" Height.) 087BP Tall (5" Ht) 087PH8. Angle Adj. Push Handle 087BP 087RG Remvable Extensin Flding Adjustable Rigidizer $75 087PH9 Lng Angle Adj. Push Handle 087B0 Tall (9"-5" Height.) 087PH8. Angle Adj. Push Handle 087PH9 Lng Angle Adj. Push Handle Flding Frame with Push Handle 087B0. (7"-" Height.) 087BP7 Swing Away Handle ( with dual triggers) 087B05 Tall (0"-6" Height.) Fixed Rigid Flding 087BP7 Swing Away Handle ( with dual triggers) HANDLE HEIGHT DIAGRAMS 8. ARMRESTS Side Guard Armrest and Armpad - Height Adjustable ( with height adjustable armrests r T-Pst) 087AA Single-Pst Height Adj.. $85 087SG Plastic $0 087AM Desk Classic 087SG9 Plastic Lw $0 087AM Desk Cntur 087AM Full Classic Armrest and Armpad 087AM Full Cntur 087AA T-Pst Regular w/fam $65 087AA9 Single-Pst Height Adj. Lw $85 087AA T-Pst Tall w/fam $65 087AM Desk Classic 087AA Flip-Up 087AM Desk Cntur 087AA Adjustable Lcking Flip-Up $65 087AM Full Classic 087AA7 Length Adjust. Lcking Flip-Up $75 087AM Full Cntur 087AM Desk Classic (0") ( w/t Pst) 087AM Full Classic (") ( w/t Pst) Armrest Receiver fr Height Adjustable Armrest 087AM9 Fam Shrt ( w/t Pst) 087AR7 Lw 087AM0 Fam Lng ( w/t Pst) 087AR8 Custmer Service: 800--000 Fax: 800-00-750 Email: rders@sunmed.cm Web: www.sunrisemedical.cm Page 5
9. KEY OPTIONS 087AO 087AT7 087A E0978 " Dual Pull Side Squeeze Padded 087A7 E0978 Belt " Aircraft Buckle 087A8 E0978 Belt " Aircraft Buckle Padded 087A E0978 Belt.5" Aut Buckle 087A8 E0978 " Cmfrt Fit APB56 087A9 087A0 087A 087A E097 E097 Anti-Tip Frnt Anti-Tip ( with caster pin lcks r transit ptin) Rear Anti-Tip $0 Psitining Belt (w/clamps) Upper Extremity Supprt Tray X-Small (Suggested 0"-" chair width) Small (Suggested "-" chair width) Medium (Suggested 5"-7" chair width) Large (Suggested 8"-0" chair width) $50 $0 $0 $70 $0 0. COLOR Spke Guard ( with ", 6" and 8" rear wheels & Prjectins Handrims) 087A K0065 Black $5 087A0 K0065 Clear Zippie $5 087A8 Canpy (SunShade) (Need " back pst clearance t munt canpy hardware, may require next height based n seating; please nte sme interference may ccur with sme headrest cnfiguratins) 0878A06 0878A07 087A 087A 087A8 Canpy (Sunshade) 0"-" Width Canpy (Sunshade) 5"-0" Width Back Pack (Kids Backpack included) Utility Backpack - Black Additinal Kids Black Backpack $60 Tl Kit Miscellaneus $75 $75 $5 Black Seat Puch $50 087C0 087C 087C 087C0 087C8 087C6 087C 087C5 087C 087C 087C6 087C 087C7 087C8 087C0 087C 087C5 087C 087C8 Standard Clrs Aztec Gld Black ( as base w/zebra) Black Cherry Black Opal Blue Opal Candy Blue Candy Purple Candy Red Electric Blue Evergreen Glw Green Apple Ht Sparkle Pink Mauve Pink Rtbeer Sparkle Silver Sunrise Orange Titanium Clr Paint Yellw 087C6 087C5 087C5 087C50 087C9 087C 087C Cmmnly Requested Optins Include: Dynamic Back Reclining Backrest Custm Andizing Custm Paint O Hlder with Transit IV Ple with Transit Standard Matte Clrs Matte Black Matte Black Cherry Matte Purple Matte Electric Blue Matte Evergreen Custm Clrs Additinal Optins Thrugh Built--Me Mssy Oak Camuflage $95 Stars and Stripes $95 Zebra 087C08 (Chse base clr abve: $95 White, black) T inquire abut any unique custmizatin fr Zippie prducts, cntact: Phne: (800) -000, Fax: (800) -90 Custmer Service: 800--000 Fax: 800-00-750 Email: rders@sunmed.cm Web: www.sunrisemedical.cm Page 6
Caster Frk Size 5-/" ( with 6" ( with 7" ( with 8" Wide (Must use with Caster Stem Zippie GS Seat Height Setup Caster Frk Hle Psitin Caster Size " " 5" 6" 8"x" 8"x.5" 65.5" Sunrise Medical (US) LLC 8 Business Park Ave. Fresn, CA 977 USA Custmer Service: 800--000 Fax: 800-00-750 Email: rders@sunmed.cm Web: www.sunrisemedical.cm Page 7