a Mark Fr: Submitting fr: Qute Order Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: ST: Dealer Phne: ( ) Address: Fax: ( ) Cnfirmatin Email: Cnfirm Via: Ship T: Attentin: Kids Quickie 2 SE (Withut Seating) NOVEMBER 2012 ZIP: Dealer City: Fax Email Ship T Phne: ( ) Fax: ( ) Optin # HCPCS a Definitin Price Optin # HCPCS Definitin Price KIDS QUICKIE 2 SE W/O SEATING PO#: Address: Ship T City: 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. EIZ10 ST: ZIP: 142WM08 E1238 Kids Quickie 2 SE W/O Seating K0005 cding still applies fr EIZ10 with certain sizes $1,950.00 142FT54 142FT55 Crss Brace w/ Seat Rails 142TO1 Transit System $315.00 Frame Type Uses Rear Side Frame Depth Adj. & Depth Adj. Back Crss Brace with Seat Rails Transit System Incl. Stabilizer Bar. N/A with Swing-Away Strller Handles and Extensin with Crss Brace with Seat Rails. 142C2 142C10 142C38 142C36 142C14 Black 142C35 Candy Red 142C128 142C6 142C127 142C126 142C116 142C117 142C4 142C5 Blue Opal Candy Blue Cpper Frest Green Fuchsia Glw Frame Clr Black Opal Candy Purple Matte Black Matte Green Midnight Purple Pearl Pink 1. FRAMES Standard Frame - 250 lbs. Maximum User Weight 142C103 142C114 142C113 142C11 142C8 Sparkle Silver Txic Green Yellw Custm Frame Clr 142C43 Mssy Oak Camuflage 142C42 142C108 142W2 Stars & Stripes 142W3 12" 142W4 13" 142W5 142W7 142W9 Frame Clr - Cntinued Rt Beer Titanium Clr Paint Zebra (Chse abve base clr) Std with White unless abve base paint is chsen. NA w/ Black Frame Width 11" (By Uphlstery) (Avail. w/crss Brace w/ Seat Rails Only) 14" 142W6 15" 16" 142W8 17" (Avail. w/crss Brace w/ Seat Rails Only) 18" (Avail. w/crss Brace w/ Seat Rails 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 2012 Sunrise Medical (US) LLC. 931165 REV. I Page 1
142FL1 Kids Frame (10"-16" Depth) 142FD3 10" Frame Depth 142FD4 11" Frame Depth 142FD5 13" Frame Depth 142FD6 15" Frame Depth 142FD7 16" Frame Depth 142FL9 Regular Frame (12"-18" Depth) 142FD3 12" Frame Depth 142FD4 13" Frame Depth 142FD 15" Frame Depth 142FD8 17" Frame Depth 142FD9 18" Frame Depth Lng Frame (14"-20" Depth) 142FD5 14" Frame Depth 142FD6 15" Frame Depth 142FD8 17" Frame Depth 142FD10 19" Frame Depth 142FD11 20" Frame Depth FRAME DEPTH AND BACK POST LOCATION Chse 1 r 2 1. Frame Depth and Back Pst Lcatin W/O Seat Rail 2. Frame Depth and Back Pst Lcatin With Seat Rail CHOOSE 1 OR 2 Frame Length 142FL1 Kids STD 142FL9 Regular 142FL18 Lng Seat Rail Length (Sling Nt Included) 142SN05 10" 142SN06 11" 142SN07 12" 142SN08 13" 142SN09 14" 142SN10 15" 142SN11 16" 142SN12 17" 142SN13 18" Back Pst Lcatin 142BL14 1" Offset Frm Seat Rail 142BL15 2" Offset Frm Seat Rail DEPTH ADJUSTABLE BACK and JAY Strller Handle (Height) 142BP27 Depth Adj. Back Pst Standard STD 142BP28 Depth Adj. Back Pst Medium 142BP29 Depth Adj. Back Pst Tall Strller Handle Optins 142BP33 Swing Away Strller Handles $100.00 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. 142JC20 Name / Part # Width: JAY Cushins (Optinal) JAY Bundled Cushin Depth: Price List ARMRESTS 142AA3 Flip Up STD 142AA9 E0973 Ht Adj. Kids $260.00 142AA1 E0973 Ht. Adj. Lcking Flip Up 142AM1 Desk Length (10") 142AA7 E0973 Ht/Length Adj. Lcking Flip Up $260.00 142AM2 Full Length (14") 142AM1 Desk Length (10") 142AA8 E0973 Ht/Length Adj. Adult $260.00 142AM2 Full Length (14") 142AM1 Desk Length (10") 142AM9 Fam Shrt 142AM2 Full Length (14") 142AM10 Fam Lng 142AA14 Omit Armrest 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. 931165 REV. I Page 2
Hanger 142F3 142E1 Shrt (see matrix fr length) 142E4 Medium (see matrix fr length) 142E5 Lng (see matrix fr length) 142E12 Shrt ELR (ELR nly) 142E16 142F1 Cmpsite Ftplate (12"-16"w) STD FOOTRESTS Chse 1 r 2 1. Hanger Type (Munt With Extensin Tube) 2. Hanger Type (Direct Munt 142H1 60 Swing-Away Hanger STD 1424H14 E0990 Extensin Tube (Required fr Optin 1) Ftplate K0037 Elevating Hanger (Only avail. w/ alum. Ftplates r angle adj. Available n 14"-18" frame widths. N/A w/ lcking angle adj. ftplates r shrt ext. tubes.) High Munt NA elevating leg rests. Only avail. w/ adult r kids angle adj. ftplates. 142F4 Kids Angle Adj. Ftplate 142E15 Lng ELR (ELR nly) $185.00 Adult Angle Adj. Ftplate (12"-16"w) $185.00 CHOOSE 1 OR 2 Hanger 142H7 142H8 142H6 Extensins (Optinal) 1.42E23 142E24 Ftplate Type 1.42E23 142E24 70 Swing Away Hangers Frnt Munt (Only avail. w/ Kids r Adult Angle Adj. r 90 ftbard ftplates) 80 Swing Away Hangers Frnt Munt (Only avail. w/ Kids r Adult Angle Adj. r 90 ftbard ftplates) 70 Swing Away Hangers (Only avail. w/ Kids r Adult Angle Adj. r 90 ftbard ftplates) 2" Extensins (n/a w/90 hangers & elevating leg rests) 4" Extensins (n/a w/90 hangers & elevating leg rests) Kids Angle Adjustable Ftplate (10" - 16" W) Adult Angle Adjustable Ftplate (Available n 12" - 16" W) $175.00 $185.00 142F48 Platfrm Flip Up Ftplate (n/a with shrt ext. tubes. Only avail. With 60 70 and 70 V) $190.00 142F5 Ftrest Optins Aluminum Ftplate Available w/ ELRs 142HL9 E0951 Heel Lps $50.00 142HL8 Impact Guard K0038 Leg Straps $35.00 142A54 K0038 Extra Leg Strap $30.00 142IG2 Neprene (Only avail. With 60 70 and 70 V) CASTERS 142CW3 Caster Wheels 4" Plyurethane $65.00 142CW5 5" Lw Prfile Plyurethane 142CW6 5" Sft Rll Semi Pneumatic 142CW33 142CW31 142CW7 6" Pneumatic (Requires selectin f Caster Tire Tube/Insert) 142CW34 6" Plyurethane STD 142CW35 142CW21 142CW32 4" Micr Lighted 5" x 1.5" Semi Pneumatic (nly avail. fr use in bttm frk hles) 6" x 1.5" Semi Pneumatic (nly avail. fr use in bttm frk hles) 8" Pneumatic (Nt avail. w/ 90 elevating leg rests. Nt avail. w/kids frame length. Requires selectin f Caster Tire Tube/Insert) 8" Plyurethane (Nt avail. w/ 90 elevating leg rests r w/kids frame length.) $70.00 142CW39 142CW36 Caster Wheels - Cntinued 142OM Omit Caster Wheels Caster Tire Tube/Insert Requires a selectin f 6", 8" r 8"x2" Pneumatic Tire. 142CZ2 K0064 8" x 1.5" Semi Pneumatic (nly avail. fr use in bttm frk hles) 8" x 2" Pneumatic (Nt avail. w/ 90 elevating leg rests. Nt avail. w/kids frame length. Requires selectin f Caster Tire Tube/Insert) Airless Insert (Only avail. With 8"x2" Pneumatic) $125.00 $65.00 142CZ1 Caster Tube (all sizes) $20.00 Caster Optins 142CS5 3/4" Lnger Frk Stem Blt 142CS10 1-1/2" Lnger Frk Stem Blt 142CS3 K0073 Caster Pin Lcks $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 2012 Sunrise Medical (US) LLC. 931165 REV. I Page 3
AXLE AND WHEELS 142AL2 Standard Adjustable Requires a selectin f Pneumatic 142AL71 E0959 Amputee Adjustable 142RZ2 E2213 Pneumatic Airless Insert $80.00 142RW3 20" Mag 142RW75 142RW54 Omit Rear Wheel Type 22" Spke 24" Spke Axle 142AX1 Quick Release STD 142AX11 Quad Quick Release $90.00 Anti-Tip 142AT6 E0971 Rear Anti-Tip $135.00 142RW74 20" Spke 142RW8 22" Mag 142RW1 24" Mag 142RT1 E2211 E2212 Axle Plate Rear Wheel Tire Pneumatic (Requires the selectin f Rear Wheel Tire/Insert) 142RT29 E2218 Full Plyurethane (avail w/mag nly) $50.00 $100.00 142RT1 E2211 E2212 Rear Wheel Tire Tube/Insert Pneumatic Tube Hand rim 142HR1 Aluminum Andized 142HR4 Plastic Cated $95.00 142HR7 Omit Wheel Lck 142WL1 High Munt Push 142WL2 High Munt Pull Extensin Handle 142EH1 E0961 6" Pair Grade Aid Requires a selectin f Rear Wheel Tire/Insert 142GA1 E0974 Grade Aid $150.00 ACCESSORIES Backpack Psitining Belt 142A1 Utility Pack - Black 142A141 E0978 Belt 1.5" Aut Buckle w/clamps $70.00 142A2 Kids Black Backpack - Zippie $50.00 142A117 E0978 Belt 2" Aircraft Buckle w/clamps $110.00 142A118 K0108 Belt 2" Aircraft Buckle w/clamps $120.00 142A112 E0978 1" Dual Pull Side Squeeze Pad w /Clmp Seat Puch 142A814 E0978 1" Cmfrt Fit APB5116 $120.00 142A8 Black $45.00 Spke Guard 142A23 K0065 Black $115.00 Crutch Hlder 142A24 K0065 Clear $115.00 142A49 E2207 Crutch Hlder $195.00 Upper Extremity Supprt Tray Miscellaneus 142A29 E0950 X-Small (Suggested 10"-12") 142A83 Tl Kit $45.00 142A30 E0950 Small (Suggested 13"-14") Side Guard 142A31 E0950 Medium (Suggested 15"-17") Nt available with height adj. flip back armrests 142SG4 K0108 Plastic Kids $125.00 142A32 E0950 Large (Suggested 18"-20") 142SG3 K0108 Plastic Regular $125.00 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. 931165 REV. I Page 4
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. 931165 REV. I Page 5