a Mark Fr: Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Cnfirmatin Email: Cnfirm Via: ZIP: Quickie LXI/LX January 2019 EILXI/EILX Submitting fr: Attentin: Address: Ship T City: Qute Fax Email 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 Definitin Price a Optin # HCPCS Definitin PO#: Ship T: Address: ST: Order ADDITIONAL SHIPPING INFORMATION ZIP: Price Fr sizes 14" r less please use HCPCS E1236 Quickie LXI (Adjustable Axle Plate) 065WM31 K0005 265 lbs Weight Capacity. 1. FRAME STYLE $2,345.00 065WM30 2. FRAME SET UP K0004 Quickie LX (Nn Adjustable Axle Plate) 250 lbs Weight Capacity $2,295.00 Includes stabilizer bar. Only n LXI. N/A w/ padded swing away armrest 065TO1 K0108 Transit System 065W3 065W4 065W5 065W6 065W7 065W8 065W9 065W41 065W11 Transit Optin Frame Width 12" 13" 14" 16" 17" 18" $125.00 E2201 20" $500.00 Seat Depth 12"-14" N/A w/ 8" casters r 24" wheels 065SD5 12" 065SD6 13" 065SD7 14" 065SD8 065SD9 16" 065SD10 17" 065SD11 18" 065SD74 $125.00 065SD13 E2203 20" $550.00 3. FRONT SEAT HEIGHT SET UP Frnt Seat Height Rear STFH ranges frm 0" t 1 1/2" lwer than frnt STFH 065SH12 065SH13 065SH14 065SH15 065SH16 065SH17 065SH18 065SH20 065SH21 065SH23 065SH24 065SH26 15.5" 16" 16.5" 17" 17.5" 18" 18.5" 19.5" 20" 20.5" (Only available n swing away) Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Page 1
3. FRONT SEAT HEIGHT SET UP (CONT) Caster Wheels 065CW3 4" Lw Prfile Plyurethane 065CW31 4" Micr Lighted $70.00 065CW72 4" x 1" Aluminum Plyurethane $110.00 065CW44 E2219 4" x 1.25" Semi Pneumatic $55.00 065CW64 4" x 1.5" Aluminum Sft Rll 065CW5 5" Lw Prfile Plyurethane 065CW51 5" Micr Lighted 065CW65 5" x 1" Aluminum Plyurethane $110.00 065CW7 E2219 5" x 1.5" Semi-Pneumatic 065CW54 E2219 5" Sft Rll (Grey) N/A w/ Frg Legs 065CW66 5" x 1.5" Aluminum Sft Rll $195.00 065CW34 6" Plyurethane 065CW33 6" Pneumatic 065CW35 E2219 6" x 1.5" Semi Pneumatic 065CW68 6" x 1.5" Aluminum Sft Rll $205.00 065CW16 7" Plyurethane 065CW32 8" Plyurethane 065CW21 8" Pneumatic 065CW39 E2219 8" x 1.5" Semi Pneumatic 065CW36 8" x 2" Pneumatic 065CW37 K0108 8" x 2" Pneumatic w/airless Insert $225.00 065CW38 Omit Caster Wheel Caster Frks 065CF62 3" 065CF9 4 3/4" 065CF12 5 1/4" 065CF17 6" 065CF23 7" 065CF29 8" x 2" 065CF30 Omit Caster Frk and Wheel Frk Stems Caster pin lcks N/A w/ 8"x2" casters 065CS1 Standard Stem 065CS5 3/4" Stem 065CS9 1 1/2" Stem 065CS7 K0073 Standard Stem w/pin Lcks $195.00 065CS11 K0073 3/4" Stem w/pin Lcks $195.00 065CS4 K0073 1 1/2" Stem w/pin Lcks $195.00 4. HANGER & FOOTPLATE OPTIONS 065H159 065H160 065H161 Hangers 065H145 60 Swing In/Out Hanger 065H139 70 Swing In/Out Hanger 065H158 90 Swing In/Out Frnt Munt Only available Ang adj adult & kids ftplates K0053 E0990 E0990 Articulating Hanger N/A w/ Platfrm Flip Up and Alum Angle Adj Frnt Munt ftplates. Elevating Hanger - Ext Munt N/A w/ Platfrm Flip Up and Alum Angle Adj Frnt Munt ftplates. Elevating Hanger - Frnt Munt Only available w/ frnt munt alum angle adj ftplates and 14"-22" width $370.00 065H32 Omit Hanger 065E2 Medium (See Matrix fr Length) Lng (See Matrix fr Length) 065E5 N/A w/ 90 hangers and ELR 065E1 Extensin Tube Shrt (See Matrix fr Lengths) N/A w/ 90 hangers and ELR 065E14 Regular ELR 065E15 Lng ELR 065E16 High Munt Only available with angle adj ftplates r 60 and 70 hangers Seat Sling t Tp f Ftrest Ftplate & Hanger Optins (Ext Tube & Direct Munt) 065HL1 E0951 Heel Lp 065HL5 K0038 Leg Strap 065HL4 Omit Heel Lp 065HL6 Omit Leg Strap 065IG2 Impact Guard Neprene Ftplates Heel lp r leg strap nt included, See Ftplate Optins Sectin Cmpsite (14"-20"w) Only available w/ 065F1 60, 70, and ALR 065F48 065F7 K0040 Platfrm Flip Up Available w/ 60, 70, r hemi hangers 065F5 065F3 K0040 Aluminum Ftplate Aluminum Angle Adj Adult 065F4 K0040 Aluminum Angle Adj Kids N/A w/ ELR. Only n 12:-16" wide Omit Ftplate & Ext Tube Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Page 2
5. REAR SEAT HEIGHT SET UP 065AX19 065AX3 065AX13 Axle Threaded Quick Release Steel Quad Quick Release One Arm Drive Only available w/ Mag Wheels. Select Standard Rim and either right r left munt 065AL16 E0958 One Arm Drive Adj. Axle Plate 065OA2 Standard Handrim 065HM1 Right Hand Munt 065HM2 Left Hand Munt $850.00 Rear Wheel Type Cntact Built 4 Me fr Spinergy Clr Optins 065RW3 065RW8 065RW1 065RW4 065RW9 065RW2 065RW11 065RW95 065RW96 065RW97 065RW98 065RW99 065RW50 20" Mag Wheel 22" Mag Wheel 24" Mag Wheel 20" Spke Wheel 22" Spke Wheel 24" Spke Wheel 26" Spke Wheel 24" Spinergy SPOX Black 25" Spinergy SPOX Black 26" Spinergy SPOX Black 24" Spinergy LX Black 25" Spinergy LX Black 24" Muntain $200.00 $200.00 $65.00 $1,060.00 $1,060.00 $250.00 065RW25 Omit Rear Wheel and Axle (Intended Size fr Set Up ) -$55.00 065RT6 065RT1 065RT2 065RT3 065RT21 E2213 E2212 E2212 Rear Wheel Tire Pneumatic Pneumatic Airless Insert Full Ply High-Pressure Clincher Schwalbe Marathn Plus Evlutin $95.00 065RT38 E2218 SHOX Perfrmance Ply $95.00 Muntain Tire Only available 065RT12 $95.00 E2212 n 24" Muntain Rear Wheel Wheel Ultra Mag Lite Spke Tire Lightweight Spinergy Pneumatic 20,22,24 20,22,24,25, 26 24,25,26 Pneumatic w/airless Insert 20,22,24 20,22,24,25,26 24,25,26 Full Ply Tire 20,22,24 20,22,24 24 High Pressure Clincher 22,24,25,26 22,24 24,25,26 Schwalbe Marathn 24,25,26 22,24 24,25,26 SHOX Perfrmance Ply 24 24,25 24,25 22" = 489 mm 24" = 540 mm 25" = 559 mm 26" = 590 mm Handrim Natural Fits available in 22", 24", and 25". 065HR1 065HR4 Aluminum Andized Plastic Cated - N/A n all rims $100.00 065HR22 065HR23 Natural Fit - Standard Grip Natural Fit - Super Grip $425.00 065HR7 Omit Hand Rims 8 Oblique Only available w/ 065HR8 aluminum handrims. N/A w/ SHOX $325.00 $140.00 6. BACKREST Back Type Angle Adj std w/ push handles and N/A w/ all flip back armrests 065BU1 Standard 065BT20 065BT22 Angle Adj 3-5" Pivt (regular) Angle Adj 5-7" Pivt (tall) Angle Adjustable Backrest Optins Angle Adjustable Pivt Height 065AH1 3" 065AH4 6" 065AH2 4" 065AH5 7" 065AH3 5" Angle Adjustable Pre-Set Angle 065BD5 065BD4 065BD3 065BD2 065BD1 Back Angle - 15 Back Angle - 12 Back Angle - 6 Back Angle - 0 Back Angle +3 Angle Adjustable Back Tube Height (See Chart) 065B1 065B5 065B9 Lw Medium Tall Angle Adjustable Back Height (Optinal) 065UX10 12" 065UX20 17" 065UX12 13" 065UX22 18" 065UX14 14" 065UX24 065UX16 065UX26 20" 065UX18 16" 065UX28 21" 065JB01 JAY Back (Optinal) J3 Back (See J3 Order Frm) Price List REFER TO CHART IN DETERMINING PUSH HANDLE LENGTH Back Tube Height Angle Adjustable Backrest Set Up 15 3 PSIS SEATING SURFACE CUSHIONTHICKNESS REGULAR 3 5 TALL 5 7 A B TO DETERMINETHEPROPER PIVOT-POINT HEIGHT, MEASURE BETWEEN THE PSIS AND THE TOP OF THE SEATING SURFACE (A), THEN ADD THE THIICKNESSOF THE CUSHION (B) IFONE ISUSED. IFADROP-SEATFALLS BELOWTHE SEAT RAILS, SUBTRACT THIS DISTAE FROM THE OVERALLVALUE. Angle Adjustable Backrest Chart Lw Medium Pivt regular set at 3" 12" 13" 14" 16" 17" 17" 18" Pivt regular set at 5" 14" 16" 17" 18" 20" 21" Tall Pivt regular set at 4" 13" 14" 16" 17" 18" 18" 20 Pivt tall set at 5" 14" 16" 17" 18" 20" 21" Pivt tall set at 6" 16" 17" 18" 20 N/A Pivt tall set at 7" 16" 17" 18" 20" 21" N/A Adjustable pivt pint present measurements frm seat sling. If back height ptin is nt chsen, middle ptin will be present. Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Page 3
6. BACKREST (CONT) Backrest Uphlstery 065BU1 Standard Uphlstery 065BU60 Tensin Adjustable Uphlstery $175.00 065BU14 Omit Back Uphlstery 065BU16 065SZ1 Backrest Optins Reinfrced Back Only available w/ Std Uphlstery $30.00 Stabilizer Bar $105.00 Push Handles 065BP1 Push Handles Straight 065BP3 Push Handles 8 (Std) $25.00 Back Height 065B92 16"- 065B86 14"-17" 7. ARMREST Armrest 065AA16 E0973 Padded Swing-Away Adult $225.00 065AA17 E0973 Padded Swing-Away Kids $225.00 065AA5 Flip-Back 065AA8 E0973 Single Pst Ht. Adjustable Adult $285.00 065AA9 E0973 Single Pst Ht. Adjustable Kids $285.00 065AA6 E0973 Flip-Back Height Adjustable 065AA14 Omit Armrest Armpad N/A w/ padded swing away armrests 065AM1 Desk Length - (10") 065AM2 Full Length - (14") Anti-Tip Accessries 065AT4 E0971 Rear Anti-Tip Wheel Lck $150.00 065A1 065A2 065A8 Quickie Backpack Black Quickie Kids Backpack Black Quickie Seat Puch Black $60.00 Additinal n gs may exist depending n wheel size, seat depth and axle psitin 065A29 065A23 E0950 K0065 Tray Table Black Spke Guards $255.00 $115.00 065WL1 High Munt Push 065A24 K0065 Quickie Clear Spke Guards $115.00 065WL2 High Munt Pull 065A54 K0038 Extra Leg Strap Black 065WL30 Cmpact $140.00 065SG4 K0108 Side Guard Plastic Kids 065WL10 Omit 065SG3 K0108 Side Guard Plastic Regular 065WL12 D Nt Munt Grade Aid 065A82 065A49 065A83 E2207 Caddy Crutch Hlder Tl Kit $195.00 $45.00 065GA1 E0974 Grade Aid N/A w/ ply, high-pressure 065A500 Velcr Gel Cver fr Hanger/Frame $105.00 $150.00 clincher tires 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 065JC20 Cushin Name r Part # Price List Width: Depth: Extensin Handle 065EH1 E0961 6" Pair Cushin Optins 065CU1 E0669 2" Cushin $120.00 065CU4 Omit Seat Sling 8. KEY OPTIONS & ACCESSORIES Military Service Patches (Optinal) Only available n tensin adjustable uphlstery and J3 Back 065VU1 065VU2 065VU3 Marines Patch Army Patch Navy Patch 065VU4 Air Frce Patch 065VU12 Cast Guard Patch 065VU5 Purple Heart Patch 065VU8 Purple Heart with Marines Patch 065VU9 Purple Heart with Army Patch 065VU10 Purple Heart with Navy Patch 065VU11 Purple Heart with Air Frce Patch 065VU13 Purple Heart with Cast Guard Patch 065A142 065A12 065A13 Psitining Belts E0978 Belt 1.5" Aut Buckle $70.00 E0978 Belt 2" Aircraft Buckle $110.00 E0978 Belt 2" Aircraft Buckle Pad $120.00 Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Page 4
8. KEY OPTIONS & ACCESSORIES (CONT) Standard Frame Clrs 065C140 Aztec Gld 065C2 Black (Nt avail as base w/zebra) 065C141 Black Cherry 065C10 Black Opal 065C38 Blue Opal 065C36 Candy Blue 065C14 Candy Purple 065C35 Candy Red 065C142 Electric Blue 065C143 Evergreen 065C126 Glw 065C144 Green Apple 065C147 Ht Sparkle Pink 065C148 Mauve Pink 065C103 065C114 065C145 065C113 065C8 Rtbeer Sparkle Silver Sunrise Orange Titanium Clr Paint Yellw Matte Frame Clrs 065C116 Matte Black 065C151 Matte Black Cherry 065C150 Matte Electric Blue 065C149 Matte Evergreen 065C152 Matte Purple Custm Frame Clr 065C112 Desert Camuflage 065C43 Mssy Oak Camuflage 065C42 Stars & Stripes 065C108 Zebra (Chse abve base clr) Std with White unless abve base paint is chsen N/A w/ Black Built fr Me T inquire abut any unique custmizatin fr Quickie prducts, cntact: Phne: (800) 333-4000, Fax: (800) 333 9011 Sunrise Medical (US) LLC 2842 Business Park Ave. Fresn, CA 93727 USA Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Page 5