a Mark Fr: Submitting fr: Qute Order Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Cnfirmatin Email: Cnfirm Via: Optin # HCPCS ZIP: 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. Definitin Quickie 7 RS March 2018 Price EIR11 a 1. FRAME Optin # PO#: Ship T: Attentin: Address: Address: Ship T City: HCPCS ADDITIONAL SHIPPING INFORMATION ST: Definitin ZIP: Price Weight capacity 265 lbs 132WM89 K0005 Base Mdel Quickie 7RS - Welded Use E1236 fr sizes 14" r less $2,795.00 Perfrmance Package (N substitutins, discunt given n separate line) 132QD01 Single Sided Frk Ultra Lightweight Wheel $250.00 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 $100.00 Ultra Lightweight Wheel $250.00 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 132FA2 75 80 85 See FIGURE 2. Frame Inset is the distance frm the utside f the seat tube t the utside f the ftrest. 132FF1 132FF2 132FF3 0" 1" (N/A w/ 12" wide) 2" (N/A 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 132IN04 Attitude Bike bundle Frame Inset Per Side Attitude Bike (Optinal) See Order Frm Figure 1 Figure 2 Figure 3 Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Page 1
2. SIZE / SEATING Seat Width See FIGURE 4 Measure frm utside f seat tube t the utside f ppsite seat tube. 132S3 12" 132S8 17" 132S4 13" 132S9 18" 132S5 14" 132S10 19" 132S6 15" 20" 132S48 $500.00 132S7 16" (E2201) 132OP01 132OP02 132OP04 Seating Systems Standard Seat Sling Ultra Seat Sling Available 14" t 18" Widths and Depths. Ultra Seat Sling will be ~1/4" less than requested seat height value. Omit Seat Sling $100.00 Seat Depth See FIGURE 5 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. Cushin 132SD5 12" 132SD10 17" 132CU1 E0669 2" Cushin $120.00 132SD6 13" 132SD11 18" 132SD7 14" 132SD12 19" 132SD8 15" 20" JAY Cushins (Optinal) 132SD13 $550.00 132SD9 16" (E2203) 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 Figure 5 Figure 6 132JC20 Cushin Name r Part # Price List Width: Depth: 3. CASTERS / SEAT HEIGHT Frnt Seat Height Caster Wheels See FIGURE 6 Measure frm the frnt f the seat rail t the flr. 132CW1 3" Micr 132SH14 16.0" 132SH20 18.5" 132CW3 4" Lw Prfile Plyurethane 132SH15 16.5" 132SH21 19.0" 132CW31 4" Micr Lighted $70.00 132SH16 17.0" 132SH23 19.5" 132CW72 4" x 1" Aluminum Ply $110.00 132SH17 17.5" 132SH24 20.0" 132CW44 E2219 4" x 1.25 Semi Pneumatic $55.00 132SH18 18.0" 132SH26 20.5" 132CW64 4" x 1.5" Aluminum Sft Rll $185.00 132SH27 21.0" 132CW5 132CW51 5" Lw Prfile Plyurethane 5" Micr Lighted Figure 7 132CW6 132CW65 132CW7 132CW66 132CW34 E2219 E2219 5" Sft Rll (Grey) -N/A w/frg Legs 5" x 1" Aluminum Ply 5" x 1.5" Semi Pneumatic 5" x 1.5" Aluminum Sft Rll 6" Ply $110.00 $195.00 132CW33 E2214 E2215 6" Pneumatic $75.00 132CW35 132CW68 E2219 6" x 1.5" Semi Pneumatic 6" x 1.5" Aluminum Sft Rll $205.00 132CF65 132CF69 132CF53 132CF54 132CF55 Caster Frk and Suspensin 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. $150.00 $425.00 $425.00 $425.00 Caster Husing Psitin See FIGURE 7. See Appendix fr example. 132LH01 Setting 1 Suggested fr 3" & 4" casters. Fr 2" Inset N/A w/ setting 1 132LH02 Setting 2 Suggested fr 5" & 6" casters. 132LH03 Setting 3 N/A w/ 6" casters Figure 7 Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Page 2
4. REAR WHEELS / SEAT HEIGHT 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" N/A w/ 24, 25 & 26" Rear Wheels and Rear Suspensin 132RH11 13.0" (N/A w/ Rear Suspensin) 132RH12 13.5" (N/A w/ Rear Suspensin) 132RH13 14.0" 132RH14 14.5" 132RH15 15.0" 132RH16 15.5" 132RH17 16.0" 132RH18 16.5" 132RH19 17.0" 132RH26 17.5" 132RH20 18.0" 132RH27 18.5" 132RH21 19.0" 132RH37 19.5" 132RH22 20.0" ( N/A w/ Rear Suspensin) 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 132HR1 Aluminum Andized 132HR4 Plastic Cated N/A w/ 25" & 26" Lite Spke Wheels 17", 18" Seat Depth 19", 20" Seat Depth 132HR22 132HR23 Camber 132HR25 132HR30 Natural Fit - N Thumb Grip Natural Fit LT - Standard Grip See FIGURE 8 132HR31 Natural Fit LT - Super Grip Frnt t Rear Seat Height Matrix 12" Seat Depth 13", 14" Seat Depth 15", 16" Seat Depth 132CI1 132CI2 132CI4 Rear Seat Height 2.5" Max Frnt t Rear Seat Hgt. 3.0" Max Frnt t Rear Seat Hgt. 3.5" Max Frnt t Rear Seat Hgt. 4.0" Max Frnt t Rear Seat Hgt. 4.5" Max Frnt t Rear Seat Hgt. 0 3 6º (N/A w/ 5 spk MAG Wheels ) Rear Wheel Ultra Lightweight nly available w/ Aluminum Handrim. Cntact Built 4 Me fr Spinergy clr ptins. 132RW103 132RW104 132RW102 132RW90 20" Mag Wheel 5 Spke 22" Mag Wheel 5 Spke 24" Mag Wheel 5 Spke 20" Lite Spke $200.00 132RW91 22" Lite Spke $200.00 132RW92 24" Lite Spke 132RW93 25" Lite Spke 132RW94 26" Lite Spke $80.00 132RW06 22" Ultra Lightweight Spke Wheel $250.00 132RW10 24" Ultra Lightweight Spke Wheel $250.00 132RW16 25" Ultra Lightweight Spke Wheel $250.00 132RW28 22" Spinergy SPOX Black Spkes $820.00 132RW95 24" Spinergy SPOX Black Spkes $820.00 132RW96 25" Spinergy SPOX Black Spkes $820.00 132RW97 26" Spinergy SPOX Black Spkes $820.00 132RW32 22" Spinergy LX Black Spkes $1,025.00 132RW98 24" Spinergy LX Black Spkes $1,025.00 132RW99 25" Spinergy LX Black Spkes $1,025.00 132RW40 26" Spinergy LX Black Spkes $1,025.00 132RW50 24" Muntain $250.00 132RT1 132RT2 132RT3 132RT38 132RT39 132RT21 132RT27 132RT12 132RT28 132HR32 132HR26 132HR27 132HR28 132HR24 132HR7 132AX1 132AX13 132AL57 132CC1 132CC2 132CC3 132CC4 132CC5 132CC6 132CC7 132CC8 Rear Wheel Tire Pneumatic E2213 Pneumatic Airless Insert $80.00 Full Ply Tire E2218 SHOX Perfrmance Ply High-Pressure Clincher Black Schwalbe Marathn Plus Evlutin $135.00 Knbby V-TRAK by Kenda Muntain Only available in 24" Schwalbe Speed Run Tire Natural Fit - Standard Grip $395.00 Natural Fit - Super Grip $425.00 $375.00 $415.00 $475.00 Natural Fit LT - N Thumb Grip $375.00 The Surge - Oval w/griptin Strip $385.00 The Surge LT - Oval w/griptin Strip $415.00 Q-Grip Neprene Cated $325.00 Spinergy Flex Rim Only available n Spinergy LX wheels 24" & 25" $650.00 Omit Handrim N/A w/ Ultra Lightweight Wheels Axle Quick Release Steel Quad Quick Release Steel Only available with Muntain Whls Axle Plate Active Rigid (.5" t 4") Adjustment range 1/2" befre and after in 1/4" increments except the.5" and 4" psitins which are maxed Center f Gravity Preset Measure frm frnt f back pst t the center f rear axle. N additinal rearward adjustment when.5" chsen. N additinal frward adjustment when 4" chsen..5" 1.0" 1.5" 2.0" 2.5" 3.0" 3.5" 4.0" Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Page 3
4. REAR WHEELS / SEAT HEIGHT (CONT) Tire 5 Spke Mag Lite Spke Wheel Ultra Lightweight Spinergy Pneumatic 20,22,24 20,22,24,26 22,24,26 Pneumatic w/ Airless Insert 20,22,24 20,22,24,26 22,24,26 Full Ply 20,22,24 20,22,24 SHOX Perfrmance Ply 20,22,24 20,22,24,25 24,25 High-Pressure Clinch Blk 22,24,26 24 22,24,26 Schwalbe Marathn 24,25,26 22,24,25 24,25,26 Knbby V Trak by Kenda 24 24 20"= 451 mm 22" = 501 mm 24" = 540 mm 25" = 559 26" = 590 Figure 8 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 132WL12 D Nt Munt Extensin Handle Ext. handles nly available with high munt push r pull wheel lcks 132EH7 E0961 Extensin Handle (Pair) $70.00 6. FOOTREST OPTIONS Ftrest Angle Adjustable Flip Back N/A w/ 19-20 wide w/ 0 inset. Sme Flip back cnfiguratins wn't allw 2 " grund clearance and will need t raise up. Flip back nt available Caster setting 1 & 2" inset. 132F229 Aluminum Tubular 132F274 Aluminum Tubular w/ Snap On Cver $30.00 132F276 K0040 Angle Adjustable Flip Back $185.00 132F325 Angle Adjustable FB Carbn Fiber $185.00 132F51 K0040 Platfrm Ftrest 132F111 132F323 K0040 Ultra Lite Platfrm Ftrest N/A w/ 14" wide and 2" inset, N/A w/ 19-20 wide w/ 0" inset Platfrm Carbn Fiber ftrest Nt available n 19"-20" W $115.00 $135.00 Adaptive Platfrm Spacer N/A 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 K0038 K0038 Ftrest Optins High Munt Ext Tubes (N/A w/ Tubular ftrest) Leg Strap Extra Leg Strap Gel Hanger Cver Neprene Impact Guards Wear Pads Psitin Plates N/A fr Tubular Ftrest $55.00 $35.00 $35.00 $105.00 7. BACKREST Back Type See FIGURE 9 Chse backrest psitin. 0 Equal is perpindicular t flr, + means frward Active Fixed Backrest 132BT97 Setting -4-2 0 +2 +4 Figure 9 Ultra Lightweight Aluminum Fixed Backrest 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" $75.00 132BB17 14" $75.00 132BB20 9" $75.00 132BB18 15" $75.00 132BB13 10" $75.00 132BB19 16" $75.00 132BB14 11" $75.00 132BB10 17" $75.00 132BB15 12" $75.00 132BB11 18" $75.00 132BB16 13" $75.00 132BB12 19" $75.00 132QT01 132QT02 Twel Bar Standard Style - 4" Offset Lw Prfile - 2" Offset Limited w/slid Backs, Nt suggested with 19" & 20" wide 132PH5 132PH2 Push Handles Fld Dwn Push Handles N/A w/ 8"- 10" fixed height N/A w/ standard uphlstery Omit Push Handles $100.00 Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Page 4
7. BACKREST (CONT) 132BU1 132BU88 132BU70 132BU71 Backrest Uphlstery Standard Uphlstery Standard Uphlstery EXO Backrest Tensin Adj Ballistic Nyln E2611 *Reference 186BU70 fr billing E2611 Backrest Tensin Adj 3DX Vented *Reference 186BU71 fr billing $315.00 $330.00 132BU89 E2611 Backrest Tensin Adj EXO *Reference XXXBU89 fr billing $330.00 132BU14 Omit Back Uphlstery -$15.00 132JB01 132VU1 132VU2 132VU3 132VU4 132VU12 132VU5 132VU8 132VU9 132VU10 132VU11 132VU13 JAY J3 Back J3 Back T rder a J3 Back please select Omit Back Uphlstery. See J3 Back Order Frm fr Part #'s. Military Service Patches US Marines Patch US Army Patch US Navy Patch US Air Frce Patch Cast Guard Patch Purple Heart Patch Purple Heart with Marines Patch Purple Heart with Army Patch Purple Heart with Navy Patch Purple Heart with Air Frce Patch Purple Heart with Cast Guard Patch Price List 8. ARMREST / SIDEGUARDS 132AA11 132AA29 132AM23 132AM21 132AM24 132AM22 Armrest - Height Adjustable Single Pst Height Adjustable - Std E0973 Range 8" - 13". Adjust in 1" increments E0973 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 (14") Classic Full Length (14") Cntur $285.00 $285.00 Increases verall width f chair. Sme interferance may exist w/ padded SA arms at lwest settings Nt available w/height Adjustable Arms 132SG33 132SG29 Plastic Standard Plastic Lw $140.00 $140.00 132SG35 Aluminum N/A w/high Push r Pull Wheel Lcks $235.00 132SG36 132SG12 Side Guards Aluminum w/ Fender N/A w/ High Push r Pull Wheel Lcks Carbn Fiber N/A w/ High Push r Pull Wheel Lcks $245.00 $450.00 Carbn Fiber Lng w/lg Fender 132SG41 $495.00 N/A w/high Push r Pull Wheel Lcks Side Guard - Clr Optin Available with Aluminum r Aluminum with Fender. Nt applicable t carbn fiber ptins 132GE01 132GE02 132GE03 Black Matching Frame- Standard Clrs Matching Frame- Custm Clr 9. KEY OPTIONS AND ACCESSORIES Anti Tips Anti Tip Single Side N/A 12W-14W range, N/A w/xtender r Rear suspensin 132AT37 E0971 Anti Tips (Pair) $140.00 132AT14 E0971 Anti Tip Single Side - Flip Up $175.00 Left Right (Facing frm rear) 132A1 132A2 1321A01 Additinal Pack Accessries Backpack - Adult $65.00 Backpack - Kids $60.00 Seat Puch Black Spke Guards Only available with Lite spke 1324A01 K0065 Quickie Black Spke Guard 1324A02 K0065 Quickie Clear Spke Guard 132A2100 1328A21 Miscellaneus E2207 Crutch Hlder Tl Kit $115.00 $115.00 $195.00 $45.00 Psitining Belt 132A824 E0978 Belt 2" Aircraft Buckle $110.00 132A825 E0978 Belt 2" Aircraft Buckle Padded $120.00 132A826 E0978 Belt 1.5" Aut Buckle Universal $70.00 132A804 Psitining Belt Clamps Only Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Page 5
10. COLOR 132C140 132C118 132C2 132C141 132C10 132C38 132C36 132C14 132C35 132C142 132C143 132C44 132C126 132C144 132C147 132C148 132C103 132C114 132C145 132C113 132C8 132C116 132C151 132C150 132C149 132C152 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 Frame Graphics Graphic designs n frnt frame tubes. N/A with transit & Matte Black Cherry. N/A w shrt height frames 1328A24 Blm 1328A25 Dragn 1328A26 Ghst Flames 1328A27 Retr Squares 1328A28 Tribal 132C112 132C43 132C42 132C108 Andized Clr Package Frks, Backcane Bracket, Rear Axle Clamp. N/A w/ Frg Legs and 132EB07 Black 132EB08 Blue 132EB13 Gld 132EB09 Lime Green 132EB10 Purple 132EB11 Red 132EB12 Ti Grey Cmmnly Requested Optins Include: Swing Away Knee Adductrs fr Oval Tubing One Arm Drive Unilateral Wheel Lcks Seat Pan Caster Pin Lck Grade Aids Active Rigid w/flding Back Spinergy Clr Spkes Custm clr casters (Alum sfrll nly) Lifestyle custm paint package (see website) Custm Frame Clr Desert Camuflage Mssy Oak Camuflage Stars & Stripes Zebra (Chse abve base clr) Std with White unless abve base paint is chsen N/A w/ Blk, Matte Black, Blk Opal, Titanium r Bead Blast) Built Fr Me T inquire abut any unique custmizatin fr Quickie prducts, cntact: Phne: (800) 333-4000, Optin #3, Fax: (800) 333 9011 Blm design Dragn design Ghst Flames design Retr Squares design Tribal design Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Page 6
11. APPENDIX Handrim & Wheel Matrix Wheels Handrims 5 Spke Mag Lite Spke Ultra Lightweight Spinergy Muntain Aluminum Andized 20,22,24 20,22,24,26 22,24,25 22,24,25,26 24 Plastic Cat 20,22,24 22,24 N/A 24,25,26 24 Natural Fit - Standard Grip 24 22,24,25,26 N/A 22,24,25,26 N/A Natural Fit - N Thumb Grip 24 22,24,25,26 N/A 22,24,25,26 N/A Natural Fit - Super Grip 24 22,24,25,26 N/A 22,24,25,26 N/A Natural Fit LT - Std Grip 24 22,24,25,26 N/A 22,24,25,26 N/A Natural Fit LT - Super Grip 24 22,24,25,26 N/A 22,24,25,26 N/A Natural Fit LT - N Thumb Grip 24 22,24,25,26 N/A 22,24,25,26 N/A Surge - Oval w/griptin Strip N/A 22,24,25,26 N/A 22,24,25,26 N/A Surge LT - Oval w/griptin Strip N/A 22,24,25,26 N/A 22,24,25,26 N/A Q Grip Neprene Cated N/A 24,25 N/A 24,25 N/A Spinergy Flex Rim N/A N/A N/A 24,25 N/A Omit Handrim 20,22,24 N/A N/A 22,24,25,26 24 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 7