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: Quickie 7 RS Octber 2015 EIR11 Fax Email Ship T Phne: ( ) Fax: ( ) a 1. FRAME PO#: Ship T: Attentin: Address: Address: Ship T City: HCPCS 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. Definitin Price Optin # ST: Definitin ZIP: Price 132WM89 K0005 Base Mdel Quickie 7RS - Welded (265 lbs) Use E1235 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 Frame Inset Per Side See FIGURE 2. Frame Inset is the distance frm the utside f the seat tube t the utside f the ftrest. 132FF1 132FF2 0" 1" (NA w/ 12" wide) 132FF3 2" (NA 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 Figure 1 Figure 2 Figure 3 Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Specificatins are subject t change withut ntice. Cpyright 2011 Sunrise Medical (US) LLC. 7RS, MK-100205 REV A 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 K0669 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 $100.00 132SH17 17.5" 132SH24 20.0" 132CW44 4" x 1.25 Semi Pneumatic $55.00 132SH18 18.0" 132SH26 20.5" 132CW64 4" x 1.5" Aluminum Sft Rll $175.00 132SH27 21.0" 132CW5 132CW51 5" Lw Prfile Plyurethane 5" Micr Lighted Figure 7 132CW6 132CW65 132CW7 132CW66 132CW34 5" Sft Rll (Grey) -NA 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 $185.00 132CW33 E2214 E2215 6" Pneumatic $75.00 132CW35 132CW68 6" x 1.5" Semi Pneumatic 6" x 1.5" Aluminum Sft Rll $195.00 Caster Frk and Suspensin Caster Husing Psitin 132CF74 Carbtecture Frks See FIGURE 7 132CF65 Multiple Psitin Setting 1 Suggested fr 3" & 4" casters. 132LH01 132CF69 Multiple Psitin Single Sided Frk Fr 2" Inset NA w/ setting 1 132CF53 E1015 Frg Legs 0 weight t 100 lbs. $425.00 132LH02 Setting 2 Suggested fr 5" & 6" casters. 132CF54 E1015 Frg Legs 101 lbs. weight t 190 lbs. $425.00 132LH03 Setting 3 NA w/ 6" casters 132CF55 E1015 Frg Legs 191 lbs. weight t 265 lbs. $425.00 Figure 7 Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Specificatins are subject t change withut ntice. Cpyright 2011 Sunrise Medical (US) LLC. 7RS, MK-100205 REV A Page 2
4. REAR WHEELS / SEAT HEIGHT Rear Seat Height Rear Wheel Tire RSH 13"-15.5" nly w/ 20" Rear Wheel. 132RT1 RSH 15"-15.5" Only w/ 20, 22 r 24" w/hp Clincher Rear Wheel. Pneumatic RSH 16"-16.5" NA w/ 24, 25 & 26" Rear Wheels and Rear Suspensin 132RT2 Pneumatic Airless Insert 132RH11 13.0" (NA w/ Rear Suspensin) E2213 $80.00 132RH12 13.5" (NA w/ Rear Suspensin) 132RT3 E2218 Full Ply Tire 132RH13 14.0" 132RT38 E2218 SHOX Perfrmance Ply 132RH14 14.5" 132RT39 High-Pressure Clincher Black 132RH15 15.0" 132RH16 15.5" 132RT21 Schwalbe Marathn Plus Evlutin 132RH17 16.0" 132RH18 16.5" 132RT27 Knbby V-TRAK by Kenda 132RH19 17.0" 132RH26 17.5" 132RT12 Muntain 132RH20 18.0" Only available in 24" 132RH27 18.5" 132RT28 Schwalbe Speed Run Tire 132RH21 19.0" 132RH37 132RH22 19.5" 20.0" ( NA w/ Rear Suspensin) Handrim Natural Fit Handrims nly available in 22", 24", & 25" Frnt t Rear Seat Height Matrix Natural Fit w/ 5 spke MAG nly available in 24". See APPENDIX 11 fr matrix 12" Seat Depth 2.5" Max Frnt t Rear Seat Hgt. 132HR1 Aluminum Andized 13", 14" Seat Depth 3.0" Max Frnt t Rear Seat Hgt. Plastic Cated NA w/ 25" & 26" 132HR4 15", 16" Seat Depth 3.5" Max Frnt t Rear Seat Hgt. Lite Spke Wheels 17", 18" Seat Depth 19", 20" Seat Depth 4.0" Max Frnt t Rear Seat Hgt. 4.5" Max Frnt t Rear Seat Hgt. Camber 132HR22 132HR23 132HR25 132HR30 Natural Fit - Standard Grip Natural Fit - Super Grip Natural Fit - N Thumb Grip Natural Fit LT - Standard Grip $410.00 See FIGURE 8 132HR31 Natural Fit LT - Super Grip $410.00 132CI1 0 132HR32 Natural Fit LT - N Thumb Grip 132CI2 3 132HR26 The Surge - Oval w/griptin Strip 132CI4 6º (NA w/ 5 spk MAG Wheels ) 132HR27 132HR28 The Surge LT - Oval w/griptin Strip Q-Grip Neprene Cated $395.00 $315.00 Rear Wheel Spinergy Flex Rim Only available 132HR24 Ultra Lightweight nly available w/ Aluminum Handrim. Cntact Built 4 Me fr n Spinergy LX wheels 24" & 25" Spinergy clr ptins. Omit Handrim 132HR7 132RW103 20" Mag Wheel 5 Spke NA w/ Ultra Lightweight Wheels $525.00 132RW104 132RW102 132RW90 22" Mag Wheel 5 Spke 24" Mag Wheel 5 Spke 20" Lite Spke $200.00 132AX1 Axle Quick Release Steel 132RW91 22" Lite Spke $200.00 Quad Quick Release Steel 132AX13 132RW92 24" Lite Spke Only available with Muntain Whls 132RW93 132RW94 132RW06 132RW10 25" Lite Spke 26" Lite Spke 22" Ultra Lightweight Spke Wheel 24" Ultra Lightweight Spke Wheel $80.00 $250.00 $250.00 132AL57 Axle Plate Active Rigid (.5" t 4") Adjustment range 1/2" befre and after in 1/4" increments except the.5" and 132RW16 25" Ultra Lightweight Spke Wheel $250.00 4" psitins which are maxed 132RW28 132RW95 22" Spinergy SPOX Black Spkes 24" Spinergy SPOX Black Spkes Center f Gravity Preset 132RW96 132RW97 25" Spinergy SPOX Black Spkes 26" Spinergy SPOX Black Spkes 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. 132RW32 22" Spinergy LX Black Spkes $995.00 132CC1.5" 132RW98 24" Spinergy LX Black Spkes $995.00 132CC2 1.0" 132RW99 25" Spinergy LX Black Spkes $995.00 132CC3 1.5" 132RW40 26" Spinergy LX Black Spkes $995.00 132CC4 2.0" 132RW50 24" Muntain $250.00 132CC5 2.5" 132RW107 24" Tplin Carbn Red Spk Whl $1,195.00 132CC6 3.0" 132RW108 24" Tplin Carbn Yellw Spk Whl $1,195.00 132CC7 3.5" 132RW109 25" Tplin Carbn Red Spk Whl $1,195.00 132CC8 4.0" 132RW110 25" Tplin Carbn Yellw Spk Whl $1,195.00 Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Specificatins are subject t change withut ntice. Cpyright 2011 Sunrise Medical (US) LLC. 7RS, MK-100205 REV A Page 3
4. REAR WHEELS / SEAT HEIGHT (CONT) 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) $65.00 6. FOOTREST OPTIONS 132F229 132F274 132F276 132F325 132F51 132F111 132F323 K0040 K0040 K0040 Ftrest Aluminum Tubular Aluminum Tubular w/ Snap On Cver Angle Adjustable Flip Back Angle Adjustable FB Carbn Fiber Platfrm Ftrest Ultra Lite Platfrm Ftrest NA w/ 14" wide and 2" inset, NA w/ 19-20 wide w/ 0" inset Platfrm Carbn Fiber ftrest Nt available n 19"-20" W $30.00 $185.00 $185.00 $115.00 $135.00 Adaptive Platfrm Spacer NA 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 K0037 K0038 K0038 Ftrest Optins High Munt Ext Tubes (NA w/ Tubular ftrest) $55.00 Leg Strap $35.00 Extra Leg Strap $35.00 Gel Hanger Cver $105.00 Neprene Impact Guards Wear Pads Psitin Plates NA fr Tubular Ftrest 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 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 Ultra Lightweight Aluminum Fixed Backrest Twel Bar Standard Style - 4" Offset Lw Prfile - 2" Offset Limited w/slid Backs, Nt suggested with 19" & 20" wide 132PH5 132PH2 132BU1 132BU70 E2611 132BU71 E2611 132BU14 Push Handles Fld Dwn Push Handles NA w/ 8"- 10" fixed height NA w/ standard uphlstery Omit Push Handles Backrest Uphlstery Standard Uphlstery Backrest Tensin Adj Ballistic Nyln *Reference 186BU70 fr billing Backrest Tensin Adj 3DX Vented *Reference 186BU71 fr billing Omit Back Uphlstery $100.00 $315.00 $330.00 -$15.00 Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Specificatins are subject t change withut ntice. Cpyright 2011 Sunrise Medical (US) LLC. 7RS, MK-100205 REV A Page 4
7. BACKREST (CONT) 132JB01 JAY J3 Back J3 Back T rder a J3 Back please select Omit Back Uphlstery. See J3 Back Order Frm fr Part #'s. Price List Military Service Patches Only available n tensin adjustable uphlstery and when rdered separate thrugh JAY J3 Back OF 132VU1 132VU2 132VU3 132VU4 US Marines Patch US Army Patch US Navy Patch US Air Frce Patch 132VU12 Cast Guard Patch 132VU5 132VU8 132VU9 Purple Heart Patch Purple Heart with Marines Patch Purple Heart with Army Patch 132VU10 132VU11 132VU13 Purple Heart with Navy Patch Purple Heart with Air Frce Patch Purple Heart with Cast Guard Patch 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 132SG35 Aluminum NA w/high Push r Pull Wheel Lcks $235.00 132SG36 132SG12 Side Guards Aluminum w/ Fender NA w/ High Push r Pull Wheel Lcks Carbn Fiber NA w/ High Push r Pull Wheel Lcks $245.00 $450.00 Carbn Fiber Lng w/lg Fender 132SG41 $495.00 NA 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 132AT37 132A1 132A2 1321A01 Anti Tips E0971 Anti Tips (Pair) $140.00 Additinal Pack Accessries Backpack - Adult $55.00 Backpack - Kids Seat Puch Black $45.00 Spke Guards Only available with Lite spke 1324A01 1324A02 K0065 K0065 Quickie Black Spke Guard Quickie Clear Spke Guard 132A2100 1328A21 Miscellaneus E2207 Crutch Hlder Tl Kit $115.00 $115.00 $195.00 $45.00 132A824 E0978 Psitining Belt 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 Specificatins are subject t change withut ntice. Cpyright 2011 Sunrise Medical (US) LLC. 7RS, MK-100205 REV A 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. NA with transit & Matte Black Cherry. NA w shrt height frames 1328A24 Blm 1328A25 Dragn 1328A26 Ghst Flames 1328A27 Retr Squares 1328A28 Tribal Blm design Dragn design 132C112 132C43 132C42 132C108 Andized Clr Package Frks, Backcane Bracket, Rear Axle Clamp. NA w/ Frg Legs and Carbtecture frks 132EB07 Black 132EB08 Blue 132EB09 Lime Green 132EB10 Purple 132EB11 Red 132EB12 Ti Grey 132EB13 Gld 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) 24",25" Glance wheels 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 NA 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 Ghst Flames design Retr Squares design Tribal design Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Specificatins are subject t change withut ntice. Cpyright 2011 Sunrise Medical (US) LLC. 7RS, MK-100205 REV A Page 6
11. APPENDIX Handrim & Wheel Matrix Wheels Handrims 5 Spke Mag Lite Spke Ultra Lightweight Spinergy Muntain Tplin Aluminum Andized 20,22,24 20,22,24,26 22,24,25 22,24,25,26 24 24,25 Plastic Cat 20,22,24 22,24 N/A 22,24,25,26 24 24,25 Natural Fit - Standard Grip 24 22,24,25,26 N/A 22,24,25,26 N/A 24,25 Natural Fit - N Thumb Grip 24 22,24,25,26 N/A 22,24,25,26 N/A 24,25 Natural Fit - Super Grip 24 22,24,25,26 N/A 22,24,25,26 N/A 24,25 Natural Fit LT - Std Grip 24 22,24,25,26 N/A 22,24,25,26 N/A 24,25 Natural Fit LT - Super Grip 24 22,24,25,26 N/A 22,24,25,26 N/A 24,25 Natural Fit LT - N Thumb Grip 24 22,24,25,26 N/A 22,24,25,26 N/A 24,25 Surge - Oval w/griptin Strip 24 22,24,25,26 N/A 22,24,25,26 N/A 24,25 Surge LT - Oval w/griptin Strip 24 22,24,25,26 N/A 22,24,25,26 N/A 24,25 Q Grip Neprene Cated N/A 24,25 N/A 24,25 N/A 24,25 Spinergy Flex Rim N/A N/A N/A 24,25 N/A N/A Omit Handrim 20,22,24 N/A N/A 22,24,25,26 24 24,25 Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Specificatins are subject t change withut ntice. Cpyright 2011 Sunrise Medical (US) LLC. 7RS, MK-100205 REV A Page 7