Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Cnfirm Via: Mark Fr: ZIP: Zippie 2 January 208 EIZ2 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 022WM0 E238 Zippie 2 - Transit Included Nte: HCPCS Cdes shwn as submitted. Sme sizes fit ther HCPC cdes i.e. 5"-6" widths = K0005 $2,750. FRAME Definitin Price 022WM02 E238 Zippie 2 - Transit Optinal $2,600 Nte: HCPCS Cdes shwn as submitted. Sme sizes fit ther HCPC cdes i.e. 5"-6" widths = K0005 2. TRANSIT SYSTEM (when Frame is rdered Transit Optinal) 022TO9 022TO3 K008 Transit Seating (Req. Selectin f Seat & Back) $250 K008 Transit w/ Seating $250 022TO7 022TO6 022TO7 K008 Transit w/ Cnv. Seating K008 Transit with Fit Seating Transit Omit (Only with Transit Included Frame) $250 $250 -$50 3. FRAME COLOR 022C40 022C2 022C4 022C0 022C38 022C36 022C4 022C35 022C42 022C43 022C26 022C44 022C47 022C48 Standard Clrs 022C03 Aztec Gld 022C4 Black ( as base w/ Zebra) 022C45 Black Cherry 022C3 Black Opal 022C8 Blue Opal Candy Blue Candy Purple 022C6 Candy Red 022C5 Electric Blue 022C52 Evergreen 022C50 Glw 022C49 Green Apple Ht Sparkle Pink Mauve Pink 022C43 022C42 022C08 Rtbeer Sparkle Silver Sunrise Orange Titanium Clr Paint Yellw Standard Matte Clrs Matte Black Matte Black Cherry Matte Purple Matte Electric Blue Matte Evergreen Custm Clrs Mssy Oak Camuflage Stars and Stripes Zebra (Chse base clr abve: White Standard, black) 4. FRAME WIDTH 022W3 022W4 022W5 2" 3" 4" 022W6 022W7 5" 6" Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm Web: www.sunrisemedical.cm /208 MK-00008 REV C Page
022FL 022FD3 022FD4 022FD5 022FD6 022FD7 5. FRAME DEPTH AND BACK POST LOCATION Kids (2" - 6") 022FL9 Regular (2" - 8") 2" 022FD3 2" 3" 022FD4 3" 4" 022FD5 4" 5" 022FD6 5" 6" 022FD7 6" 022FD8 7" 022FD9 8" 6. SEATING 022ST6 022B3 022B7 022B 022ST27 E223 Seats Slid Seat/Back Shrt (2") Medium (4") Tall (6") Omit Slid Seat/Back $200 N/C N/C N/C Width (in.): 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 022JC20 JAY Bundled Cushin Cushin Name r Part # Depth (in.): Price List 7. STROLLER HANDLE BACK POSTS FOR ADAPTIVE SEATING - BACK RESTS 022BP9 022BP0 022BP 022BP3 022RG Fixed Height Lw (9" Ht) Medium (22" Ht) Tall (25" Ht) Remvable Extensin Flding Adjustable Rigidizer $75 022B80 022BP47 022B8 022BP47 Height Adjustable Flding Frame with Push Handle. (7"-23" Height.) Swing Away Handle Tall (20"-26" Height.) Swing Away Handle Fixed Height Height Adjustable HANDLE HEIGHT DIAGRAMS JAY Backs (Optinal) Ordering JAY backs n-chair, See the JAY Price List. Requires Part # 022JB02 JAY Bundled Backrest Backrest Name r Part # Width (in.): Height (in.): Price List 8. ARMRESTS Armrest and Armpad - Height Adjustable 022AA2 E0973 T-Pst Regular w/ Fam $265 022AA3 022AA3 E0973 T-Pst Tall w/ Fam Flip-Up $265 022AA E0973 Adjustable Lcking Flip-Up $255 022AA7 E0973 Length Adjust. Lcking Flip-Up $265 022AM23 Desk Length (0") 022AM24 Full Length (4") 022AM9 Fam Shrt ( w/ T-Pst) 022AM0 Fam Lng ( w/ T-Pst) 022AA 022AM23 022AM2 022AM24 022AM22 022AA29 022AM23 022AM2 022AM24 022AM22 Armrest - Height Adjustable E0973 Single-Pst Height Adj.. E0973 Desk Classic Desk Cntur ( w/ 2"-3" Depth) Full Classic Full Cntur ( w/ 2"-3" Depth) Single-Pst Height Adj. Lw Desk Classic Desk Cntur ( w/ 2"-3" Depth) Full Classic Full Cntur ( w/ 2"-3" Depth) $285 $285 Armrest Receiver fr Height Adjustable Armrest 022AR7 Lw ( w/ 20" rear wheels) 022AR8 Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm Web: www.sunrisemedical.cm /208 MK-00008 REV C Page 2
8. ARMRESTS (Cnt.) Armrest Size Transfer Tube Length (D) 8" 5-/4" Receiver CLASSIC PAD Height Range (H) Pad Length (L) Desk Full 0-/4" t 5-3/4" 8-3/4" t 3-3/4" 9" t 3" 0-/4" 4" 7-/4" t -/4" Armrest Size Transfer Tube Length (D) 8" 5-/4" Receiver CONTOUR PAD Height Range (H) Pad Length (L) Desk Full 0" t 5" 8-/4" t 2-/2" 8-/2" t 2-/2" 0-/2" 4-/4" 6-3/4" t 0-3/4" Armrest Matrix fr Single Pst 9. FOOTRESTS Ext. Tube Munted Ftrests (Ftplates Munt t Ext. Tube) Hanger Type 022HL 022H32 E095 Heel Lps Omit Hanger 022H85 60 Swing In/Out 022F7 Omit Ftplate & Ext. Tube 022H86 70 Swing In/Out 022HL4 Omit Heel Lp 022H6 80 Swing In/Out 022HL6 Omit Single Leg Strap ( with 6" r 8" Casters) Hanger Munted Ftrest (Ftplates Munt t Hanger Tubing) Hanger Type 022H89 70 Swing In/Out Frnt Munt 022H90 80 Swing In/Out Frnt Munt 022H9 90 Swing In/Out Frnt Munt 022H9 70 HD Frnt Munt Lift-Off 022H0 80 HD Frnt Munt Lift-Off 022H 90 HD Frnt Munt Lift-Off 022H4 E0990 90 Elevating Extensins (may interfere with sme seat heights & casters) 022E23 2" (nt munted) 022E24 4" (nt munted) 022F9 022F8 022F62 022H24 022H4 022E 022E2 022E5 022E6 K0053 Kids Angle Adjustable ( w/ 7"-8" widths) Adult Angle Adj. (Available with 0"-8" widths) E0990 Ftbard (Available with 0"-6" widths) Extensins Shrt (.5" - 4") Med (4" - 7") ( w/ ELR) Lng (7" - 9") High Munt Ftplate Articulating ( w/ 2"-3" cmpsite ftplate) Elevating ( w/ cmpsite r platfrm ftplates r < 6" width) $50 $350 022F 022F3 022F4 022F5 022F48 022F27 022IG2 022A54 022A0 E095 Platfrm Flip-Up (Available n 60, 70, and 80 ext. $90 munt hangers nly) K0038 E0952 Ftplate Cmpsite ( In 0", " r 2" width) Aluminum Angle Adjustable Kids Angle Adjustable ( w/ 7"-8" width) Aluminum (Only available with elevating leg rests 4"-8") Cmpsite Angle Adj. (6"-22"w) Ftrest Hanger Optins Neprene Cvers (Avail. n 60 / 70 /80 ext. munt hangers nly) Extra Single Leg Strap Te Lp (Only avail. w/ adult angle adjustable ftplates) $50 $30 $40 $30 -$5 -$5 Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm Web: www.sunrisemedical.cm /208 MK-00008 REV C Page 3
0. CASTERS 022CS3 022CW30 022CW3 022CW3 022CW5 022CW5 022CW7 022CW33 022CW34 022CW35 022CW2 022CW32 022CW39 022CW36 022CW37 022CS5 022CS9 022CW38 Caster Wheel Frnt Seat t Flr Height Guide (Reference Only) 3" Micr Light Up $65 Rear Wheel CASTER SIZE 4" Micr Light Up $70 Size 3" 4" 5" 6" 8"x" 8"x.5" 4" Plyurethane 6.5" 6.5" 6.5" 6.5" 2" 5" Micr Light Up 7.0" 7.0" 7.0" 7.0" 5" Lw-Prfile Plyurethane 2" 5.5" 5.5" 5.5" 5.5" E229 5" x.5" Semi-Pneumatic Lw Ply 6.0" 6.0" 6.0" 6.0" E224 5.5" 5.5" 5.5" 5.5" 6" Pneumatic $75 6" E225 6.0" 6.0" 6.0" 6.0" 6" Plyurethane 5.0" 5.0" 5.0" E229 6" x.5" Semi-Pneumatic 5.5" 5.5" 5.5" E224 8" Pneumatic ( w/ 90 Hangers r kids 8" 6.0" 6.0" 6.0" 6.0" E225 frame length) 6.5" 6.5" 6.5" 6.5" E229 E224 E225 E224 K008 K0073 8" Plyurethane ( w/ 90 Hangers r kids frame length) 8" x.5" Semi-Pneumatic ( w/ 90 Hangers r kids frame length) 8" x 2" Pneumatic ( w/ 90 Hangers r kids frame length) 8" x 2" Pneumatic Inserts ( w/ 90 Hangers r kids frame length) Caster Optins $225 3/4" Lnger Frk Stem Blt -/2" Lnger Frk Stem Blt Caster Pin Lcks ( with 8" x 2" r Transit Opt.) Omit Caster, Wheels & Tires $45 $95 20" 22" 24" 7.0" 7.0" 5.0" 5.5" 6.0" 6.5" 7.0" 7.5" 5.5" 6.0" 6.5" 7.0" 7.5" 9.0" 6.0" 6.5" 7.0" 7.5" 9.0" 9.0" 9.0" 9.0" 9.0" 9.0" 5.5" 5.5" 6.0" 6.0" 6.5" 7.5" 5.5" 6.0" 6.5" 7.0" 7.5" 9.0" 6.0" 6.5" 7.0" 7.5" 9.5" 7.0" 5.0" 5.0" 6.5" 5.5" 6.0" 6.5" 7.0" 7.5" 9.0" 9.5" 20.0" 6.0" 6.5" 7.0" 7.5" 9.0" 6.0" 6.0" 6.5" 6.5" 7.0" 7.5" 7.0" 6.0" 6.5" 7.0" 7.0" 7.0" 7.0" 7.5" 9.5" 20.0" 7.5" 7.5" 7.5" 9.0" 7.5" 9.5" 9.5" 20.0" 20.0" 9.0" 7.5" 9.0" 9.0" 9.5" Based n rear seat t flr height up t.5" lwer than frnt seat t flr height. T achieve desired seat height see matrices n last page. Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm Web: www.sunrisemedical.cm /208 MK-00008 REV C Page 4
022OA 022RW48 022RW4 022AL2 Standard 022AL8 E0959 Amputee $75 022AL6 022OA2 022HM 022HM2 022HM 022HM2 Left 022AX 022AX E0958 Small Handrim ( w/ 20" rear wheels) Right Axle Plate One Arm Drive (Available with 3"-6" widths nly) ( w/ amputee axle plate, 2", 6" r 8" wheels.) Standard Handrim Right Left Axle Quick Release Quad Quick Release ( with Lite Spkes) Rear Wheel Size 2" Mag ( with handrims) 6" Mag ( with handrims) $25 022WL0 Omit Rear Wheel Size - Cnt 022RW3 20" Mag Extensin Handle 022RW8 22" Mag 022EH E096 6" Pair $75 022RW 24" Mag 022RW2 8" Spke $00 Anti-Tip 022RW74 20" Lite Spke Frnt Anti-Tip 022AO E097 022RW75 22" Lite Spke ( with caster pin lcks r transit pt.) $50 022RW54 24" Lite Spke $00 022AT E097 Rear Anti-Tip $40 022RW25 Omit Rear Wheel & Axle - Rear Wheel Tire 022RT Pneumatic. AXLES AND WHEELS 0 $40 022HR 022HR4 022HR7 022HR8 8 Oblique $325 022LK0 022LK02 022WL 022WL2 022WL25 Handrim Aluminum Andized Plastic Cated Omit ( with wheel/axle credit) Prjectins ( n Plastic Cated) Only available with 24" wheels Hub Lck *Only available with 2" r 6" wheels. with One Arm Drive. Ft Lck (May limit flding width & w/ 24" rear wheels and kids frame.) $95 2" Hub Lck $00 6" Hub Lck $00 Wheel Lck with Hub Lck High Munt Push ( w/ kids frame and 24" rear wheels) High Munt Pull ( w/ kids frame and 24" rear wheels) 022RT2 022RT3 022RT4 022RT6 E22 E223 E22 E222 Pneumatic Airless Insert Full Plyurethane ( w/ 2", 6", and 8" rear wheels) Lw Plyurethane (Only available with 2" and 24" wheels ) High Pressure Clincher (Avail. with 24" spke wheels, with mag wheels) $80 $95 2. ACCESSORIES Back Pack (Kids Backpack included) 022A Utility Backpack - Black $65 022A2 Additinal Kids Black Backpack $60 Seat Puch 022A8 Black $50 Miscellaneus 022A82 Caddy $50 022A83 Tl Kit $45 022A49 E2207 Crutch Hlder-Assm. Fld Chair $95 Spke Guard ( with 2", 6" and 8" rear wheels r prjectins) 022A23 K0065 Black $5 022A303 K0065 Clear Zippie $5 Upper Extremity Supprt Tray 022A29 E0950 X-Small (Suggested 0"-2" chair width) $255 022A30 E0950 Small (Suggested 3"-4" chair width) $255 022A3 E0950 Medium (Suggested 5"-7" chair width) $255 022A32 E0950 Large (Suggested 8"-20" chair width) $255 Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm Web: www.sunrisemedical.cm /208 MK-00008 REV C Page 5
2. ACCESSORIES Cnt. Psitining Belt (w/ clamps) Side Guard 022A2 E0978 " Dual Pull Side Squeeze Padded ( with height adjustable armrests and T-Psts) 022A7 E0978 Belt 2" Aircraft Buckle $0 022SG33 K008 Plastic. $40 022A8 E0978 Belt 2" Aircraft Buckle Padded $20 022SG29 K008 Plastic Lw $40 022A4 E0978 Belt.5" Aut Buckle w/ clamps $70 022A84 E0978 " Cmfrt Fit APB56 $20 Canpy (SunShade) Caster Frk Size 5-/4" ( with 6" ( with 7" ( with 8" Wide (Must use with Caster Stem +-/2" +-/2" +-/2" +-/2" Zippie 2 Seat Height Setup Caster Caster Size Frk Hle 3" 4" 5" 6" 8"x" 8"x.5" Psitin 5.0" 2 5.0" 5.5" 6.0" 3 5.0" 5.5" 6.0" 6.5" 4 5.5" 6.0" 6.5" 7.0" 6.0" 6.5" 2 6.0" 6.5" 7.0" 3 6.0" 6.5" 7.0" 7.5" 4 6.5" 7.0" 7.5" 9.0" 6.5" 2 6.5" 7.0" 7.5" 3 6.5" 7.0" 7.5" 4 7.0" 7.5" 9.5" 9.5" 6.0" 6.5" 2 6.0" 6.5" 7.0" 7.5" 3 6.0" 6.5" 7.0" 7.5" 4 6.5" 7.0" 7.5" 9.0" 6.5" 7.0" 2 6.5" 7.0" 7.5" 3 6.5" 7.0" 7.5" 9.0" 9.0" 4 7.0" 7.5" 9.5" 9.5" 7.5" 2 7.5" 9.5" 9.0" 3 7.5" 9.0" 20.0" 9.5" 4 9.0" 9.5" 20.5" 20.0" 7.0" 7.5" 2 7.0" 7.5" 9.0" 3 7.0" 7.5" 9.5" 9.0" 4 7.5" 9.0" 20.5" 9.5" 7.5" 9.0" 9.0" 2 7.5" 9.5" 9.5" 3 7.5" 9.0" 20.0" 20.0" 4 9.0" 9.5" 20.5" 20.5" 9.0" 20.0" 9.5" 2 9.0" 9.5" 20.5" 20.0" 3 9.0" 9.5" 20.0" 2.0" 20.5" 4 9.0" 9.5" 20.0" 20.5" 2.5" 2.0" 2 9.0" 2 9.5" 9.5" 2 20.5" (Need 2" back pst clearance t munt canpy hardware, may require next height based n seating; please nte sme interference may ccur with sme headrest cnfiguratins) 0228A06 0228A07 K008 Canpy (Sunshade) 0"-4" Width K008 Canpy (Sunshade) 5"-20" Width $275 $275 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 Web: www.sunrisemedical.cm /208 MK-00008 REV C Page 6