a Mark Fr: Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Cnfirmatin Email: Cnfirm Via: ZIP: Quickie 2HP January 2017 EIHP Qute Fax Email Ship T Phne: ( ) Fax: ( ) Optin # HCPCS Definitin Price a Optin # 1. FRAME Submitting fr: PO#: Ship T: Attentin: Address: Address: Ship T City: HCPCS ST: Definitin Order ADDITIONAL SHIPPING INFORMATION 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. ZIP: Price 018WM33 018WM33 018TO1 K0005 K0005 Base mdels 60 Fixed Frnt Frame 70 Fixed Frnt Frame NA w/ Kids Frame r 8" Casters Transit System Transit System NA w/ Padded SA Armrests, Strller Handles r Xtender Pwer Assist; Includes Stabilizer Bar $2,325.00 $2,325.00 $315.00 018RS2 018RS1 Rear Frame Type (250 lbs. Weight Capacity) Rear Side Frame Runded Lwest tw axle plate psitins NA w/ 20" rear wheels and 8" caster Rear Side Frame Straight Heavy-Duty - 350 lbs. Maximum Weight Limit NA w/ Xtender Pwer Assist. Package includes: Tri-Crss Brace, Reinfrced Back Uphlstery, Stabilizer Bar 018HV1 Heavy Duty $500.00 018W2 018W3 018W4 018W5 018W6 018W7 018W8 018W9 018W10 018W11 018W12 018W13 2. SIZE / SEATING Frame Width Seat Depth 11" (by uphlstery) 17" - 20" Available nly n lng frame r extra lng frame fr 19"-20" deep. 12" 17" and 18" sling depths NA w/70 shrt frame r 60 kids frame 19" -20" Extra lng frame steel reinfrced. 14" 018SD3 10" 15" 018SD4 11" 16" 018SD5 12" 17" 018SD6 18" 018SD7 14" 19" 018SD67 15" E2201 20" $500.00 018SD9 16" E2201 21" (Only Avail. w/ Heavy Duty) $500.00 018SD10 17" E2201 22" (Only Avail. w/ Heavy Duty) $500.00 018SD11 18" 018SD72 19" Frame Length 018SD13 E2203 20" $550.00 Kids / Shrt 60 & 70 NA w/ HD Package, 26" rear wheels r 17" and 18" sling depths 018FL2 018FL7 Kids 60 Shrt 60 (10"-14" nly) (10"-11", -17" nly) 018CU1 E0669 Cushin 2" Cushin $120.00 018FL12 Regular 60 (-17" nly) 018CU2 Omit Cushin 018FL22 Lng 60 (15"-18" nly) 018CU4 Omit Sling 018FL27 X-Lng 60 (17"-20" nly) 018FL8 Shrt 70 (10"-11", -16" nly) JAY Bundled Cushins - Optinal 018FL13 Regular 70 (-17" nly) T rder any JAY cushins n-chair, please see JAY Price List. Cushin name 018FL23 Lng 70 (15"-18" nly) r part number must be filled ut with desired width & depth. 018FL28 X-Lng 70 (17"-20" nly) JAY Bundled Cushin 018JC20 Cushin Name r Part #: Price List Width: Depth: Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Specificatins are subject t change withut ntice. Cpyright 2012 Sunrise Medical (US) LLC. Quickie 2HP MK-100061 REV F Page 1
3. CASTERS 018CW3 018CW1 018CW31 018CW5 018CW6 018CW33 018CW7 018CW34 018CW35 018CW21 018CW32 018CW36 018CW37 018CW12 Caster Wheels 3" Micr NA w HD package 4" Lw Prfile Plyurethane NA w/ HD package 4" Micr Lighted NA w/ HD package $70.00 5" Lw Prfile Plyurethane 5" x 1.5" Semi-Pneumatic nly avail. fr use in bttm frk hles 5" Sft Rll (Grey) NA w/ Frg Legs 6" Pneumatic 6" Plyurethane 6" x 1.5" Semi-Pneumatic nly avail. fr use in bttm frk hles 8" Pneumatic 8" Plyurethane 8" x 2" Pneumatic 8" x 2" Pneumatic w/airless Insert Omit Casters $145.00 $225.00 018CF46 018CF44 018CF29 018CS5 018CS9 018CS3 E1015 K0073 Caster Frk Multi Psitin Frk Frg Legs NA w/ 8" casters. NA w/ Xtenders Pwer Assist 8"x2" Frk Caster Frk Optins 3/4" Lnger Frk Stem Blt 1-1/2" Lnger Frk Stem Blt Caster Pin Lcks N/A w/8"x2" NA w/ Xtender r Frg Legs $425.00 $195.00 4. REAR WHEELS / SEAT HEIGHT Xtender Pwer Assist RSH f 14.5"-20" fr 22" rear wheels and RSH 15.5"-21" fr 24" wheels. NA w/ Transit r HD Optins. 22" & 24" wheels nly. Dual Drive mde available with B4ME. Higher seat heights may be available thrugh Built 4 Me. 018XT6 E0986 22" Xtender Pwer Assist JWX-2 NICKEL $7,895.00 018XT7 E0986 22" Xtender Pwer Assist JWX-2 LITHIUM $8,695.00 018XT4 E0986 24" Xtender Pwer Assist JWX-2 NICKEL $7,895.00 018XT5 E0986 24" Xtender Pwer Assist JWX-2 LITHIUM $8,695.00 Please select ne f the fllwing handrim ptins 018XH5 Plastic Cated 018XH6 Stainless Steel Xtender - Other Optins 018XA10 Spare NiMH Pwer Pack - NICKEL $1,395.00 018XA11 Spare Li-in Pwer Pack - LITHIUM $1,795.00 018XA8 018XA9 018XA2 018XA4 Xtender Wheel Optins SPARE 22" Lite Spke Pneu Alum SPARE 22" Lite Spke Pneu Plastic SPARE 24" Lite Spke Pneu Alum SPARE 24" Lite Spke Pneu Plastic $90.00 $90.00 Rear Wheel Type Ultra Lightweights nly available w/ silver andized aluminum handrim and HP clincher tire. 018RW3 018RW4 018RW8 018RW9 018RW1 018RW2 018RW11 20" Mag Wheel 20" Spke Wheel 22" Mag Wheel 22" Spke Wheel 24" Mag Wheel 24" Spke Wheel 26" Spke Wheel $200.00 $200.00 $65.00 018RR25 Omit Rear Wheel and Axle (Intended Size fr Set Up ) -$55.00 018RW77 22" Ultra Lightweight Spke Wheel $250.00 018RW78 24" Ultra Lightweight Spke Wheel $250.00 Perfrmance Wheel Type Cntact Built 4 Me fr Spinergy Clr Optins 018RW42 24" Spinergy (540) SPOX Black 018RW43 24" Spinergy (559) SPOX Black 018RW88 24" Spinergy (540) LX Black 018RW89 24" Spinergy (559) LX Black 018RT6 018RT1 018RT2 018RT3 E2218 Rear Wheel Tire Pneumatic Pneumatic Airless Insert Full Ply Available in 20",22" & 24" High-Pressure Clincher N/A w/ Perfrmance $795.00 $795.00 $995.00 $995.00 $80.00 018RT21 Schwalbe Marathn Plus Evlutin 018RT38 E2218 SHOX Perfrmance Ply Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Specificatins are subject t change withut ntice. Cpyright 2012 Sunrise Medical (US) LLC. Quickie 2HP MK-100061 REV F Page 2
4. REAR WHEELS / SEAT HEIGHT (Cnt.) Hand Rim Natural Fits available in 22" and 24". Handrim selectin NA w/ Xtender. Ultra lightweight wheels nly available w/ alum andized handrim 018HR1 018HR4 018HR7 Aluminum Andized Plastic Cated Omit Hand Rim 018HR22 Natural Fit - Standard Grip $375.00 018HR23 Natural Fit - Super Grip $410.00 Prjectin Hand Rim Only available with MAGs r Spke wheels. 018HR8 8 Oblique $325.00 018AL2 018AL6 018AL5 018AL29 E0959 Axle Plate Standard Adjustable Amputee Adjustable Lwest 2 axle plate psitins NA w/ runded rear frame, 20" rear wheels with 8" casters Curved Adjustable Offset Adjustable NA w/ swing-away r flip-back armrests; height adjustable armrests available at swing-away price $175.00 018AX1 018AX11 018AX30 Axle Quick Release Steel Quad Quick Release Omit One Arm Drive N/A with amputee axle plate,26" rear wheels, r 21" r 22" seat widths, Xtender Pwer Assist, 11" r 12" frame width, HD package, padded SA armrests, and anti-tip. Only available fr use in bttm frk hles and mag wheel. Rear seat height will adjust in 1/2" increments. Rear seat height will be 1/4" lwer than std 018AL16 E0958 018OA1 018HM2 018HM1 018OA2 018HM2 018HM1 One Arm Drive Adj. Axle Plate Small Handrim (NA w/ 20" wheels) Left Hand Munt Right Hand Munt Standard Handrim Left Hand Munt Right Hand Munt $850.00 5. WHEEL LOCKS 018WL1 018WL2 018WL14 018WL5 Wheel Lck High Munt Push High Munt Pull High Munt Right Push/Left Pull High Munt Scissr NA w/ extensin handles, grade aides, kids frame, shrt frame, r highest axle plate psitin n rear frame 018EH1 018GA1 E0961 E0974 Extensin Handle 6" Pair Grade Aid Grade Aid NA w/ ply, high-pressure clincher tires, r kids length frames $150.00 018WL10 018WL12 Omit D Nt Munt 6. FOOTREST Ftplates Heel lp r leg strap nt included, See Ftplate Optins Sectin 018F1 Cmpsite Available n 14"-22" widths 018F3 K0040 Aluminum Angle Adj Available n 14"- 22" widths 018F48 018F7 K0040 Platfrm Flip Up NA w/ shrt extensin tubes Omit Ftplate & Ext Tube $185.00 $190.00 018HL1 018HL5 018HL4 018HL6 018IG2 E0951 K0038 Ftplate Optins Heel Lp Leg Strap Omit Heel Lp Omit Leg Strap Impact Guard Impact Guard Neprene $35.00 Ftrest Extensin Tubes 018E1 Shrt (14"-16 1/2") 018E2 Medium (16 1/2"-19") 018E5 Lng (19"-21 1/2") High Munt Only avail. w/ angle 018E16 K0037 adj ftplates $55.00 Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Specificatins are subject t change withut ntice. Cpyright 2012 Sunrise Medical (US) LLC. Quickie 2HP MK-100061 REV F Page 3
7. BACKREST / SEATING 018B1 018B5 018B9 018BP3 018BP2 018BP4 Backrest Optins (Available w/ Optin 1 r 2) Push Handle 8 Med.r Tall nly, NA pt. 2 Backrest Uphlstery 018BU1 Standard Uphlstery 018BU8 Adjustable Uphlstery $175.00 018BU16 Reinfrced Included w/hd ptin 018BU14 Omit Back Uphlstery 018SR2 018SR3 Back Type - Chse Optin 1 r Optin 2 OPTION 1 - Standard Backrest Lw (8.5"-12") Medium (12"-15.5") Tall (15.5"-19") Strller Handles Regular Strller Handles Tall Strller Handles $25.00 Omit Push Handle Straight N/A w/hd Omit Push Handle 8 N/A w/hd $25.00 NA w/ push handles when angle adjustable back is selected. NA w/ amputee axle plate, flip back r flip back height adj arms OPTION 2 - Angle Adjustable Backrest (+3 t -15 ) Select pivt pint, back height and back tube - see chart fr ptins NA w/ flip-back r flip-back height adjustable armrests. 018BT20 Angle Adjustable Regular Pivt $185.00 018AH1 Angle Adjustable Pivt 3 018AH2 Angle Adjustable Pivt 4 018AH3 Angle Adjustable Pivt 5 018BT22 Angle Adjustable Tall Pivt $185.00 018AH3 Angle Adjustable Pivt 5 018AH4 Angle Adjustable Pivt 6 018AH5 Angle Adjustable Pivt 7 Optinal Pre-Set Angle 018BD5 Back Angle - 15 018BD4 Back Angle - 12 018BD3 Back Angle - 6 018BD2 Back Angle - 0 018BD1 Back Angle +3 Back Tube Height (See Chart) 018B1 Lw 018B5 Medium 018B9 Tall Optinal Back Height (See Chart fr Desired Height) 018B56 12" 018B57 018B58 14" 018B59 15" 018B60 16" 018B61 17" 018B62 18" 018B63 19" 018B64 20" 018B65 21" 018JB01 JAY Back (Optinal) J3 Back (See J3 Order Frm) Price List ANGLE ADJUSTABLE BACKREST CHART Back Tube Height LOW MEDIUM TALL Pivt Regular set at 3" 12" 14" 15" 16" 17" 17" 18" 19" Pivt Regular set at 4" 14" 15" 16" 17" 18" 18" 19" 20" Pivt Regular set at 5" 14" 15" 16" 17" 18" 19" 19" 20" 21" Pivt Tall set at 5" 14" 15" 16" 17" 18" 19" 19" 20" 21" Pivt Tall set at 6" 15" 16" 17" 18" 19" 20" N/A Pivt Tall set at 7" 16" 17" 18" 19" 20" 21" N/A Adjustable Pivt Pint Preset Measurement frm Seat Sling 8. ARMREST / SIDE GUARDS NA w/ kids frame, amputee axle plate, ext. handles, grade aids, highest axle plate psitin n runded rear frame. NA w/ angle adjustable back rest 018AA6 018AA9 018AA8 Armrest E0973 Flip Back Height Adj (Classic) 018AM2 Full Length - Cntur (14") E0973 Height Adjustable Kids 018AM2 Full Length - Cntur (14") E0973 Height Adjustable Adult 018AM2 Full Length - Cntur (14") $285.00 $285.00 018AA5 018AA16 018AA14 E0973 Armrest (Cnt) Flip Back NA w/ kids frame, amputee axle plate, ext. handles, grade aids, highest axle plate psitin n runded rear frame,. NA w/ angle adjustable back rest Padded Swing-Away Adult N/A w/ amputee axle plate. Omit Armrest Omit Armrest $210.00 Side Guard Plastic side guards NA w/ height adj. arms. Side guard interference w/ Padded SA arms at sme heights may exist. 018SG3 018SG4 Plastic Regular Plastic Kids Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Specificatins are subject t change withut ntice. Cpyright 2012 Sunrise Medical (US) LLC. Quickie 2HP MK-100061 REV F Page 4
9. KEY OPTIONS & ACCESSORIES 018AT1 018A1 018A2 018A8 018A49 E0971 E2207 Rear Anti-Tip Rear Anti-Tip $140.00 Backpack Quickie Backpack Black $55.00 Quickie Kids Backpack Black $50.00 Seat Puch Quickie Seat Puch Black Crutch Hlder Crutch Hlder $195.00 NA w/ Xtender Pwer Assist; Only available w/ Mag and Lite Spke wheels 018A23 K0065 Black Spke Guards $115.00 018A24 K0065 Clear Spke Guards $115.00 018A141 018A117 018A118 018A120 018A31 Psitining Belts E0978 Belt 1.5" Aut Buckle w/clamps E0978 Belt 2" Aircraft Buckle w/clamps E0978 Belt 2" Aircraft Buckle Pad w/clamp Psitining Belt Slide Clamps Spke Guards Wheelchair Tray Table E0950 Tray Table $70.00 $110.00 $120.00 $50.00 $250.00 Extra Leg Strap 018A54 K0038 Extra Leg Strap Black 018A82 018A83 Caddy Tl Kit Miscellaneus 10. COLOR Standard Frame Clrs 018C140 Aztec Gld 018C2 Black (Nt avail as base w/zebra) 018C141 Black Cherry 018C10 Black Opal 018C38 Blue Opal 018C36 Candy Blue 018C14 Candy Purple 018C35 Candy Red 018C142 Electric Blue 018C143 Evergreen 018C126 Glw 018C144 Green Apple 018C147 Ht Sparkle Pink 018C148 Mauve Pink 018C103 Rtbeer 018C114 Sparkle Silver 018C145 Sunrise Orange 018C113 Titanium Clr Paint 018C8 Yellw 018C116 018C151 Matte Frame Clrs Matte Black Matte Black Cherry 018C150 Matte Electric Blue 018C149 Matte Evergreen 018C152 Matte Purple 018C112 018C43 018C42 018C108 Custm Frame Clr Desert Camuflage Mssy Oak Camuflage Stars & Stripes Zebra (Chse abve base clr) Std with White unless abve base paint is chsen NA w/ Blk, Matte Black, Blk Opal r Titanium) BUILT FOR ME T inquire abut any unique custmizatin fr Quickie prducts, cntact: Phne: (800) 333-4000, Fax: (800) 333 9011 Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Specificatins are subject t change withut ntice. Cpyright 2012 Sunrise Medical (US) LLC. Quickie 2HP MK-100061 REV F Page 5