Zippie TS SE Nvember 2012 EIZ1A Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer City: ST: Dealer Phne: ( ) Address: Fax: ( ) Cnfirm Via: Mark Fr: ZIP: Dealer Address: SUBMITTING FOR: Qute Order Ship T: Attentin: Address: Ship T City: 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. PO#: ST: ZIP: a Optin # HCPCS a Definitin Optin # HCPCS Definitin ZIPPIE TS SE 1. FRAME STYLE All Zippie TS mdels grw in width and depth. 187WM67 E1234 Flding Grwing Zippie TS $2,575.00 187WM68 187F02 E1233 Rigid Grwing Zippie TS Additinal Rigid Strut Tube $2,450.00 2. TRANSIT SYSTEM Tie Dwn Requires: Slid Seat and Slid Back r, Grwing Seat Pan and Jay Fit r Cnventinal Seat and Back r, Grwing Seat Pan and Slid Back r, Jay Fit and/r Cnventinal Seat & Back 187TO32 Transit Optinal Seating (Req. Selectin f Seat & Back) $200.00 187TO31 Transit Optinal w/ Seating 187TO33 Transit Omit $200.00 N/C 3. TILT OPTION 187TT12 187VZ01 187VZ02 Dual Trigger Cable Release Criss Crss Cables (cables are lnger individually) Nn Criss Crss Std 4. FRAME COLOR Standard Clrs 187C4 Midnight Purple 187C2 Black (Nt avail as base w/zebra) 187C5 Pearl Pink 187C10 187C103 Black Opal Rtbeer Blue Opal 187C38 187C114 Sparkle Silver 187C36 Candy Blue 187C113 Titanium Clr Paint 187C14 Candy Purple 187C11 Txic Green 187C35 Candy Red 187C8 Yellw 187C128 Cpper 187C6 Frest Green Custm Clrs 187C127 Fuchsia 187C43 Mssy Oak Camuflage $295.00 187C126 Glw 187C42 Stars and Stripes $295.00 187C116 Matte Black 187C108 Zebra (Chse base clr abve: $295.00 187C117 Matte Green White Std, n/a black) 187TT8 Cable Ft Release (may limit flding width) ORDER INFORMATION: Custmer Service: 800-333-4000 Fax: 800-300-7502 www.sunrisemedical.cm Specificatins are subject t change withut ntice. Cpyright 2012 Sunrise Medical 113286 REV.G Page 1
Mark Fr: 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. a Optin # a Optin # HCPCS Definitin 5. FRAME WIDTH 187S1 187S2 187S3 Small Crss Brace 10" 11" 12" 187W25 187W27 187S5 187S6 187S7 Large Crss Brace 14" 15" 16" 187W26 187S4 187S5 Medium Crss Brace 187W28 12" 187S3 187S7 13" 187S8 14" 187S9 X-Large Crss Brace 16" 17" 18" 6. FRAME DEPTH AND BACK POST LOCATION 187FD4 187FD5 187FD6 187FD7 187FD8 187FD9 13" Frame Depth 14" Frame Depth 15" Frame Depth 16" Frame Depth 17" Frame Depth 18" Frame Depth 187FD10 19" Frame Depth (uses rear frame extensin plug) 187FD36 20" Frame Depth (uses rear frame extensin plug) Figure 6.1 - Frame Depth Diagram 7. SEATING Seats REFEREE ONLY 187ST55 E2231 Slid Seat (Req. Slid Back) Nt avail. w/10"13" W x 19" and 20" Frame Depth r 17"-18" W x 13"-17" Frame Depth. 187ST14 187ST5 E2231 Grwing Seat Pan Depth (Fig. 7.1) Omit Seat $100.00 Depth Range Seat Depth Pan Size Minimum Maximum Medium 13"-14" 11 3/4" 16 1/4" $150.00 Lng 15"-17" 13 3/4" 18 1/4" Std X-Lng 18"-20" 15 3/4" 20 1/4" 187PU4 Backs (Slid Back Depth = 2" Less Than Frame Depth) Shrt Slid Back 12" (Requires slid seat) 187PU5 Med. Slid Back 14" 187PU6 Tall Slid Back 16" 187BT13 Omit Backrest 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 187JC20 Cushin Name r Part # List Width: Depth: Depth Figure 7.1 - Frame Depth Grwth Range Matrix ORDER INFORMATION: Custmer Service: 800-333-4000 Fax: 800-300-7502 www.sunrisemedical.cm Specificatins are subject t change withut ntice. Cpyright 2012 Sunrise Medical 113286 REV.G Page 2
Mark Fr: 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. a Optin # a Optin # HCPCS Definitin 8. STROLLER HANDLE BACK POSTS - BACK RESTS Fixed Height 187BP9 Lw (19" Ht) 187BP10 Medium (22" Ht) 187BP11 Tall (25" Ht) 187BP13 Remvable Extensin $85.00 187RG1 Flding Adjustable Rigidizer $175.00 Height Adjustable Rigid Frame w/ Angle Adjust Push Handle 187B202 Std. (16"-22" Height.) 187PH8 Std. Angle Adj. Push Handle Lgth 187PH9 Lng Angle Adj. Push Handle Length 187B203 Tall (19"-25" Height.) 187PH8 Std. Angle Adj. Push Handle Lgth 187PH9 Lng Angle Adj. Push Handle Length Flding Frame with Push Handle 187B204 Std. (17"-23" Height.) 187BP47 Swing Away Handle (nt available $55.00 with dual triggers) Fixed Rigid Flding FIGURE 9.1 - HANDLE HEIGHT DIAGRAMS 187B205 Tall (20"-26" Height.) 187BP47 Swing Away Handle (nt available $55.00 with dual triggers) 9. ARMRESTS Armrest and Armpad - Height Adjustable Armrest - Height Adjustable 187AA12 E0973 T-Pst Regular w/fam 187AA11 E0973 Single-Pst Height Adj. Std. $260.00 187AA13 E0973 T-Pst Tall w/fam 187AM23 Desk Classic 187AA3 E0973 Flip-Up 187AM21 Desk Cntur 187AA1 E0973 Adjustable Lcking Flip-Up $250.00 187AM24 Full Classic 187AA7 E0973 Length Adjust. Lcking Flip-Up $260.00 187AM22 Full Cntur 187AM23 Desk Length (10") 187AA29 E0973 Single-Pst Height Adj. Lw $260.00 187AM24 Full Length (14") 187AM23 Desk Classic 187AM9 Fam Shrt (nt avail. w/t Pst) 187AM21 Desk Cntur 187AM10 Fam Lng (nt avail. w/t Pst) 187AM24 Full Classic 187AM22 Full Cntur Armrest Receiver fr Height Adjustable Armrest 187AR17 Lw (nt avail. w/lite Spkes) 187AR18 Std Armrest Size Transfer Tube Length D 8" LOW 5 1/4" CLASSIC PAD Receiver Pad Length L H Range Desk Full 10 3/4" t 15 3/4" LOW 8 3/4" t 13 3/4" 10 1/4" 14" 9" t 13" LOW 7 1/4" t 11 1/4" Armrest Size Transfer Tube Length D 8" LOW 5 1/4" CONTOUR PAD Receiver Pad Length L H Range Desk Full 10" t 15" LOW 8 1/4" t 12 1/2" 8 1/2" t 12 1/2" 10 1/2" 14 1/4" LOW 6 3/4" t 10 3/4" Armrest Matrix fr Single Pst ORDER INFORMATION: Custmer Service: 800-333-4000 Fax: 800-300-7502 www.sunrisemedical.cm Specificatins are subject t change withut ntice. Cpyright 2012 Sunrise Medical 113286 REV.G Page 3
Mark Fr: 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. a Optin # a Optin # HCPCS Definitin 10. FOOTRESTS Hanger Munted Ftrest (Ftplates Munt t Hanger Tubing) Ftrest Hanger Optins Hanger Type 187IG2 Neprene Cvers (Avail. n 60 / $85.00 187H89 187H90 70 Swing In/Out Frnt Munt 80 Swing In/Out Frnt Munt 187HL1 E0951 70 /80 ext. munt hangers nly) Heel Lps $30.00 187H91 187H9 90 Swing In/Out Frnt Munt 70 Hvy Dty Fnt Munt Lift-Off 187A110 E0952 Te Lp (Only avail. w/ adult angle adjust. ftplates) $40.00 187H10 80 Hvy Dty Fnt Munt Lift-Off 187HL5 K0038 Leg Strap $35.00 187H11 90 Hvy Dty Fnt Munt Lift-Off 187H32 Omit Hanger ($15.00) Extensins (may interfere with sme seat heights & casters) 187H23 E0990 90 Elevating $295.00 (nt avail w/ 10-11" Wide) 187F7 187HL4 187HL6 Omit Ftplate & Ext. Tube Omit Heel Lp Omit Single Leg Strap ($15.00) 187E23 2" (nt munted) $55.00 Rear CASTER SIZE Wheel 187E24 4" (nt munted) $55.00 Size 3 4 5 6 8x1 8x 8x2 1.5 Ftplate 17.0 16.5 16.5 17.0 187F9 Kids Angle Adjustable $185.00 12 17.5 17.0 17.0 17.5 (nt avail. w/17"-18" widths) 17.5 17.5 18.0 187F8 Adult Angle Adj. $185.00 12 16.0 16.0 16.0 (Available with 10"-18" widths) Lw Ply 16.5 16.5 16.5 16.5 N/A N/A N/A 187F62 Ftbard (Available with 10"-16" widths) 187H14 E0990 Elevating (Nt avail. w/ cmpsite r platfrm ftplates, r <16" width) 15.5 15.5 15.5 16 18.0 18.0 18.0 18.0 18.0 15.5 15.5 15.5 20 17.0 17.0 17.0 17.0 17.5 17.5 17.5 187E2 Med (14" - 17") Nt avail. w/ ELR 16.5 16.5 16.5 16.5 187E5 Lng (17" - 19") 17.0 17.0 17.0 17.0 187E16 K0037 High Munt $55.00 17.5 17.5 17.5 17.5 18.0 187F271 Ftplate Cmpsite (nt avail. In 10", 11" r 12" width) Aluminum (Only available with elevating legrests 14"-18") Platfrm Flip-Up (Avail n 60 70 and 80 ext. munt hangers nly) Cmpsite Angle Adj (16"-22"w) $185.00 Ext. Tube Munted Ftrests (Ftplates Munt t Ext. Tube) Hanger Type 16.0 16.0 16.0 18 16.5 187H85 60 Swing In/Out 16.5 16.5 16.5 187H86 70 Swing In/Out 17.0 187H116 80 Swing In/Out 15.5 15.5 15.5 187H24 K0053 Articulating (nt avail w/ 10"-13" $350.00 16.0 16.0 16.0 cmpsite ftplates.) 16.5 16.5 16.5 16.5 $295.00 Extensins 18.0 18.0 18.0 18.0 187E1 Shrt (11.5" - 14") 187F1 187F3 187F4 187F5 187F48 Aluminum Angle Adjustable Kids Angle Adjustable (nt avail. w/17"-18" width) $185.00 $185.00 $190.00 $150.00 22 24 18.0 18.0 18.0 18.0 17.0 19.5 17.5 17.5 17.5 17.5 18.0 18.0 18.0 18.0 18.0 19.5 17.5 18.0 Chart A - Seat t Flr Height Matrix Shaded Caster Sizes nt available with ft actuated wheel lck. Nte: Rear seat-t-flr ht. may be up t 1.5" lwer than frnt seat-t-flr ht. N/A 19.5 19.5 N/A 20.0 20.0 20.0 N/A 19.5 20.0 ORDER INFORMATION: Custmer Service: 800-333-4000 Fax: 800-300-7502 www.sunrisemedical.cm Specificatins are subject t change withut ntice. Cpyright 2012 Sunrise Medical 113286 REV.G Page 4
Mark Fr: 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. a Optin # a Optin # HCPCS Definitin 11. CASTERS 187CW7 187CW33 Caster Wheel 187CW21 E2214 8" Pneumatic $75.00 187CW30 3" Micr Light Up $65.00 E2215 187CW31 4" Micr Light Up $70.00 187CW32 8" Plyurethane 187CW51 5" Micr Light Up $85.00 187CW39 8" x 1.5" Semi-Pnuematic $85.00 187CW5 5" Lw-Prfile Plyurethane 187CW36 8" x 2" Pneumatic $145.00 E2214 E2215 5" x 1.5" Semi-Pneumatic $85.00 6" Pneumatic $75.00 187CW37 187CW34 6" Plyurethane 187CW35 6" x 1.5" Semi-Pneumatic $85.00 187CS3 E2214 E2215 E2214 K0108 K0073 8" x 2" Pneumatic w/airless Insert Caster Optins Caster Pin Lcks (Nt available with 8" x 2" and 8" x 1.5" casters) $225.00 $195.00 12. AXLES AND WHEELS 187AL18 Axle Plate Rear Wheel Size 12" Rear Wheel Axle Plate (Only avail. w/12" r 16" rear wheels) 187RW13 12" Mag (Nt available with handrims) 187AL34 187AL35 187AL17 E0958 One Arm Drive (Avail. w/ 20", 22", 24" Mag Rear Wheels & 13"-18" width) $850.00 187RW3 187RW8 20" Mag 22" Mag 187OA2 Standard Handrim 187RW1 24" Mag 187HM1 187RW12 Right 18" Spke $100.00 187HM2 Left 187RW90 20" Lite Spke $200.00 187OA1 Small Handrim (nt avail w/ 20" wheels) 187RW91 187RW54 22" Lite Spke 24" Lite Spke $200.00 $100.00 187HM1 187HM2 Right Left 187AX26 187AX1 187AX11 Shrt Adjustable (Nt available with 12" rear wheels) Lng Adjustable (Nt available with 12" rear wheels) Axle One Arm Drive Axle (Only avail. w/one Arm Drive Optin) Quick Release Quad Quick Release (nt available with Lite Spkes) $90.00 187RW14 187RT1 187RT2 E2211 E2212 16" Mag (Nt available with handrims) Rear Wheel Size - Cnt Rear Wheel Tire Pneumatic Pneumatic Airless Insert $80.00 187RT3 E2218 Full Plyurethane (Nt avail.w/ 12", 16" and 18" rear wheels) 187RT4 E2211 E2213 Lw Plyurethane (Only available with 12" r 24" wheels ) 187RT6 E2211 E2212 High Pressure Clincher (Only available with 24" spke wheels) $95.00 ORDER INFORMATION: Custmer Service: 800-333-4000 Fax: 800-300-7502 www.sunrisemedical.cm Specificatins are subject t change withut ntice. Cpyright 2012 Sunrise Medical 113286 REV.G Page 5
Mark Fr: 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. a Optin # a Optin # HCPCS Definitin 12. AXLES AND WHEELS - CONT. Handrim Wheel Lck 187HR1 187HR4 Aluminum Andized Plastic Cated $95.00 187WL1 Nt available with Hub Lck High Munt Push 187HR7 Omit (Nt available with 187WL2 High Munt Pull wheel/axle credit) 187WL25 187WL10 Ft Lck (may limit flding width) Omit Prjectins (Nt Available n Plastic Cated) *Only available with 24" wheels & nt available with spke guards. Extensin Handle 187HR8 8 Oblique $240.00 187EH1 E0961 6" Pair $75.00 Hub Lck *Only available with 12" r 16" wheels. Nt avail. w/ ne arm drive. 187LK01 12" Hub Lck $100.00 187LK02 16" Hub Lck $100.00 Anti-Tip 187AO1 E0971 Frnt Anti-Tip (Nt available with caster pin lcks) (Nt available with transit ptin) $150.00 187AT1 E0971 Rear Anti-Tip $135.00 13. ACCESSORIES Back Pack (Kids Backpack included) 187A1 Utility Backpack - Black $55.00 (Nt available with 12", 16" and 18" rear wheels & Prjectins Handrims) 187A2 Additinal Kids Black Backpack $50.00 187A23 K0065 Black $115.00 187A303 K0065 Clear Zippie $115.00 Seat Puch 187A8 Black $45.00 Miscellaneus 187A83 Tl Kit $45.00 Psitining Belt (w/clamps) 187A112 E0978 1" Dual Pull Side Squeeze Padded $85.00 187A117 E0978 Belt 2" Aircraft Buckle $110.00 187A118 E0978 Belt 2" Aircraft Buckle Padded $120.00 187A141 E0978 Belt 1.5" Aut Buckle w/clamps $70.00 (Nt available with height adjustable armrests r T-Pst armrests) 187A814 E0978 1" Cmfrt Fit APB5116 $120.00 187SG33 K0108 Plastic Std $125.00 Spke Guard Upper Extremity Supprt Tray When rdering a tray with full armrest r desk armrest pads, add 1" t seat width t determine best tray size. 187A29 E0950 X-Sm (Suggested 10"-12" Width) $250.00 187A30 E0950 Sm (Suggested 13"-14" Width) $250.00 187A31 E0950 Med (Suggested 15"-17" Width) $250.00 187A32 E0950 Lrg (Suggested 18"-20" Width) $250.00 Side Guard 187SG29 K0108 Plastic Lw $125.00 ORDER INFORMATION: Custmer Service: 800-333-4000 Fax: 800-300-7502 www.sunrisemedical.cm Specificatins are subject t change withut ntice. Cpyright 2012 Sunrise Medical 113286 REV.G Page 6