Quickie QXi March 2015

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a Mark Fr: Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Cnfirmatin Email: Cnfirm Via: ZIP: Quickie QXi March 2015 EIF6 Submitting fr: Address: Address: Ship T City: Qute Fax Email Ship T Phne: ( ) Fax: ( ) Optin # HCPCS Definitin Price a Optin # HCPCS Definitin Price 1. FRAME STYLE & SETUP PO#: Ship T: Attentin: ST: 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: Base Mdel 196WM78 K0005 Quickie QXi (265 lbs) Fr 14" sizes use E1236 $1,845.00 Frame Style See Seat Height Matrix n page 2 196FS9 Standard Frame 196FS30 Hemi Frame Frame Width 196W5 14" 196W6 15" 196W7 16" 196W8 196W9 18" 196W10 19" 196W11 E2201 20" $500.00 Transit 196TO38 Transit System $315.00 196SD7 196SD8 196SD9 14" 15" 16" 196SD10 196SD11 196SD71 196SD13 E2203 18" 19" 20" Seat Depth $550.00 Quickie QXi, Ultra Lightweight Adjustable Flding Wheelchair Quickie QXi featuring the Jay ION cushin 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. (12.11) QXi March 2015, MK-100024 REV B Page 1

2. FRONT SEAT HEIGHT SET UP Frnt Seat Height Frnt Seat Height Matrix See Frnt Seat Height Matrix. 12.5 & 13.0 nly available w/ 60 hanger 12.5" & 13" nly available w/ Alum Angle Adj Ftplate 196SH34 12.5" 196SH14 16.0" Standard Stem Blt 196SH35 13.0" 196SH15 16.5" 196SH40 13.5" 196SH16 17.0" 196SH41 14.0" 196SH17 17.5" 4 Lw Ply 14.5 15.0 12.5 13.0 16.0 17.0 14.0 15.0 196SH42 14.5" 196SH18 18.0" 4 x 1.25 Semi Pneu 15.0 15.5 13.0 13.5 16.5 17.5 14.5 15.5 196SH12 15.0" 196SH20 18.5" 5 Lw Ply 15.0 15.5 13.0 13.5 16.5 17.5 14.5 15.5 196SH13 15.5" 196SH21 19.0" 5 x 1.5 Semi Pneu 15.0 15.5 13.0 13.5 16.5 17.5 14.5 15.5 196SH23 19.5" 6 Ply N/A N/A N/A N/A 17.0 18.0 15.0 16.0 N/A N/A N/A N/A 17.0 18.0 15.0 16.0 Wheels 8 Ply N/A N/A N/A N/A 19.0 19.0 17.0 17.0 196CW3 4" Lw Prfile Plyurethane 8 x 1.5 Semi Pneu N/A N/A N/A N/A 18.5 19.0 16.5 17.0 196CW44 4" x 1.25" Semi Pneumatic $55.00 6" FORK 7" FORK 196CW5 5" Lw Prfile Plyurethane 196CW7 5" x 1.5" Semi Pneumatic $85.00 4 Lw Ply 17.5 18.0 15.5 16.0 18.5 19.0 16.5 17.0 196CW34 6" Plyurethane 4 x 1.25 Semi Pneu 17.5 18.0 15.5 16.0 18.5 19.0 16.5 17.0 196CW35 6" x 1.5" Semi Pneumatic $85.00 5 Lw Ply 17.5 18.5 15.5 16.5 18.5 19.5 16.5 17.5 196CW32 8" Plyurethane 5 x 1.5 Semi Pneu 17.5 18.5 15.5 16.5 18.5 19.5 16.5 17.5 196CW39 8" x 1.5" Semi Pneumatic Frk $85.00 6 Ply 8 Ply 17.5 19.0 15.5 17.0 18.5 N/A 16.5 18.0 17.5 19.0 15.5 17.0 18.5 N/A 16.5 18.0 19.5 N/A 17.5 18.0 19.5 N/A 17.5 19.0 196CF71 3.5" (standard stem blt nly) 8 x 1.5 Semi Pneu 18.5 19.5 16.5 17.5 19.0 N/A 17.0 18.5 196CF12 196CF17 196CF23 5.25" 6" 7" Fr 3/4" and 1 1/2" Stem blt matrix see page 5 D 196CS1 196CS5 196CS9 Stem Blt Standard 3/4" 1 1/2" 3. HANGER & FOOTPLATE OPTIONS Frnt Hangers Ftplate munts with Extensin Tube using clamping hardware 196H145 60 Swing In/Out Hanger 196H139 70 Swing In/Out Hanger 196H141 80 Swing In/Out Hanger 196H159 196H160 196H161 K0053 E0990 E0990 Articulating Hanger NA w/ Platfrm Flip Up and Alum Angle Adj Frnt Munt ftplates. Elevating Hanger - Ext Munt NA w/ Platfrm Flip Up and Alum Angle Adj Frnt Munt ftplates. Elevating Hanger - Frnt Munt Only available w/ frnt munt alum angle adj ftplates and 14"-22" width $350.00 $295.00 $295.00 196H144 Omit Hanger & Ftplate Ftplate Heel lp nt included, see Ftplate Optin sectin belw 196F1 Cmpsite Ftplate 196F3 K0040 Aluminum Angle Adj. Ftplate 196F5 Aluminum Only available w/elevating Legrest 196HL12 1968A02 Hanger & Ftplate Optins E0951 Adjustable Heel Lp Gel Cver Fr Hangers (Pair) $185.00 $35.00 $110.00 Extensin Tubes See Lwer Leg Length Matrix fr range 196E1 196E2 196E5 Shrt Medium Lng 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. (12.11) QXi March 2015, MK-100024 REV B Page 2

4. REAR SEAT HEIGHT SET UP Rear Seat Height Matrix Rear Wheel Size See Rear Tire & Wheel Matrix fr availability Rear Wheel Size 20" Rear Wheel 22" Rear Wheel 24" Rear Wheel 25" Rear Wheel 26" Rear Wheel Std Frame 13.0" - 16.5" 14.0" - 17.5" 15.0" - 18.5" 15.5" - 19.0" 16.0" - 19.5" Rear Seat Height Hemi Frame 12.0" - 15.0" 12.5" - 16.0" 13.5" - 17.0" 14.0" - 17.5" 14.5" - 18.0" 196RW3 196RW8 196RW1 196RW90 196RW91 196RW92 196RW100 196RW101 20" Mag Wheel 22" Mag Wheel 24" Mag Wheel 20" Lite Spke Wheel 22" Lite Spke Wheel 24" Lite Spke Wheel 25" Lite Spke Wheel 26" Lite Spke Wheel See Rear Seat Height Matrix 196RW25 Omit 196RH9 12" 196RH10 196RH11 12.5" 13" Rear Wheel Tire See Rear Tire & Wheel Matrix fr availability 196RH12 13.5" 196RT1 196RH13 14" E2212 Pneumatic 196RH14 14.5" 196RT2 Pneumatic w/ Airless Insert 196RH15 15" E2213 $80.00 196RH16 15.5" 196RT3 E2218 Full Ply 196RH17 16" 196RT6 High-Pressure Clincher 196RH18 16.5" E2212 $95.00 196RH19 196RH26 17.5" Handrim 196RH20 18" Natural Fit nly available w/ 22, 24, 25 Lite Spke. Plastic NA w/ 25, 26" 196RH27 18.5" 196HR1 Aluminum Andized 196RH21 19" 196HR4 Plastic $95.00 Seat Squeeze Matrix 196HR22 196HR23 Natural Fit - Standard Grip Natural Fit - Super Grip $375.00 $410.00 Frame Depth Max Seat Squeeze 14" 2.0" 15" - 16" 2.5" - 18" 2.5" 19" - 20" 3.0" Rear Tire & Wheel Matrix Wheel Tire Mag Spke Pneumatic 20,22,24,26 20,22,24,26 Pneumatic w/ Airless Insert 20,22,24,26 20,22,24,26 Full Ply Tire 20,22,24 20,22,24 High Pressure Clincher N/A 22,24,25,26 22" = 489 mm 24" = 540 mm Extensin Handle Ext. handles nly available with high munt push r pull wheel lcks 196EH7 E0961 Extensin Handle (Pair) 196WL1 196WL2 196WL30 196WL10 196WL12 196AX1 196AX11 Wheel Lck High Munt Push High Munt Pull Cmpact Omit Wheel Lck D Nt Munt Axle Quick Release Steel Quad Quick Release Steel NA n Spke $65.00 5. ARMREST Sme limitatins when used with the Angle Adjustable Back in the rear mst setting Please circle a setting, will default t 11" if n selectin is made E0973 Padded Swing-Away (9" t 13") $210.00 196AA18 Setting 9" 10" 11" 12" 13" Armrest - Padded Swing Away Armrest - Height Adjustable 196AA104 E0973 Single Pst Ht. Adj - Std (9.75"-14.75") $285.00 196AA105 E0973 Single Pst Ht Adj - Lw (8.25"-12.25") $285.00 196AA65 E0973 Flip Back Ht Adj LITE (10"-15") $295.00 196AA14 Omit Armrest 196AA103 E0973 Dual Pst Flip Back Ht Adj $295.00 196AM23 196AM24 1968A01 Armpad - Fr Height Adjustable Desk Length (10") Full Length - Full (14") Armrest Optins Gel Cver Fr Swing Away Arms (pair) $110.00 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. (12.11) QXi March 2015, MK-100024 REV B Page 3

6. BACKREST Back Type 196BT10 Standard 196BT100 Angle Adjustable Back $165.00 Backrest Height 196B5 Med (13"-) 196B9 Tall (16"-20") 196BU1 196BU70 196BU71 196BU14 Back Uphlstery Standard Uphlstery E2611 Backrest Tensin Adj Ballistic Nyln *Reference 186BU70 fr billing $315.00 E2611 Backrest Tensin Adj 3DX Vented *Reference 186BU71 fr billing $330.00 Omit Back Uphlstery -$15.00 196PH6 196PH5 196PH2 Push Handles Integral Push Handles 8 fr Std Backrest, Straight fr Angle Adj. Backrest Fld-Dwn Push Handles Only available with Adjustable Uphlstery. Used in cmbinatin w/angle Adjust nly avail in 16"-20" Omit Push Handles 8 fr Std Backrest, Straight fr Angle Adj. Backrest $100.00 196JB01 JAY J3 Back JAY J3 Back See OF Military Service Patches Only available n tensin adjustable uphlstery and Jay 3 Back 196VU1 196VU2 196VU3 196VU4 US Marines Patch US Army Patch US Navy Patch US Air Frce Patch 196VU12 US Cast Guard 196VU5 196VU8 196VU9 Purple Heart Purple Heart with Marines Patch Purple Heart with Army Patch 196VU10 196VU11 196VU13 Purple Heart with Navy Patch Purple Heart with Air Frce Patch Purple Heart with Cast Guard 7. SEATING Seat Sling 196SL23 Seat Sling Depth Adjustable 196SL6 Omit Seat Sling -$15.00 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 196JC20 Cushin Name r Part # Price List Width: Depth: 8. Key Optins & Accessries 196AT1 E0971 Anti Tips Anti Tips (Pair) $140.00 1964A01 Spke Guards K0065 Quickie Black Spke Guard $115.00 196SG33 196SG29 Side Guards K0108 Plastic - Standard (8.5" High) K0108 Plastic - Lw (6.5" High) 1968A03 196A2100 E2207 Miscellaneus Caddy Crutch Hlder $45.00 $195.00 Pack Accessries 196A1 Backpack - Black/Charcal Adult $55.00 1961A01 Seat Puch Black $45.00 Psitining Belt 196A141 E0978 1.5" Aut Buckle w/ Clamps $70.00 196A804 K0108 Psitining Belt Slide Clamps $50.00 Frame Clr 196C2 Black 196C10 Black Opal 196C38 Blue Opal 196C36 Candy Blue 196C35 Candy Red 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. (12.11) QXi March 2015, MK-100024 REV B Page 4

8 Ply 4 Lw Ply 4 x 1.25 Semi Pneu 5 Lw Ply 5 x 1.5 Semi Pneu 6 Ply 8 Ply 4 Lw Ply 4 x 1.25 Semi Pneu 5 Lw Ply 5 x 1.5 Semi Pneu 6 Ply 8 x 1.5 Semi Pneu 8 x 1.5 Semi Pneu Frnt Seat Height Matrix Cnt. 3/4" STEM 1 1/2" STEM N/A N/A N/A N/A 17.0 18.0 15.0 16.0 4 Lw Ply N/A N/A N/A N/A 17.5 18.5 15.5 16.5 N/A N/A N/A N/A 17.0 18.0 15.0 16.0 4 x 1.25 Semi Pneu N/A N/A N/A N/A 17.5 18.5 15.5 16.5 N/A N/A N/A N/A 17.0 18.0 14.5 15.5 5 Lw Ply N/A N/A N/A N/A 18.0 19.0 16.0 17.0 N/A N/A N/A N/A 17.5 18.5 15.5 16.5 5 x 1.5 Semi Pneu N/A N/A N/A N/A 18.0 19.0 16.0 17.0 N/A N/A N/A N/A 17.5 18.5 15.5 16.5 6 Ply N/A N/A N/A N/A 18.5 19.5 16.5 17.5 N/A N/A N/A N/A 17.5 18.5 15.5 16.5 N/A N/A N/A N/A 18.5 19.5 16.5 17.5 N/A N/A N/A N/A 19.5 19.5 17.5 17.5 8 Ply N/A N/A N/A N/A N/A N/A 18.5 18.5 N/A N/A N/A N/A 19.0 19.5 17.0 17.5 8 x 1.5 Semi Pneu N/A N/A N/A N/A 19.5 19.5 17.5 18.0 6" FORK 7" FORK 18.0 18.5 16.0 16.5 19.0 19.5 17.0 17.5 4 Lw Ply 19.0 19.5 17.0 17.5 N/A N/A 18.0 18.5 18.0 18.5 16.0 16.5 19.0 19.5 17.0 17.5 4 x 1.25 Semi Pneu 19.0 19.5 17.0 17.5 N/A N/A 17.5 18.5 18.0 19.0 16.0 17.0 19.0 19.5 17.0 18.0 5 Lw Ply 18.5 19.5 16.5 17.5 19.5 19.5 17.5 18.5 18.0 19.0 16.0 17.0 19.0 19.5 17.0 18.0 5 x 1.5 Semi Pneu 19.0 19.5 17.0 18.0 N/A N/A 18.0 19.0 18.0 19.5 16.0 17.5 19.0 19.5 17.0 18.5 6 Ply 18.5 19.5 16.5 18.0 19.5 19.5 17.5 19.0 18.0 19.5 16.0 17.5 19.0 19.5 17.0 18.5 18.5 19.5 16.5 18.0 19.5 19.5 17.5 19.0 N/A N/A 18.0 18.5 19.5 19.5 18.0 19.5 8 Ply N/A N/A 18.5 19.0 N/A N/A 18.5 19.5 19.0 19.5 17.0 18.0 19.5 19.5 17.5 19.0 8 x 1.5 Semi Pneu N/A N/A 18.0 19.0 N/A N/A 18.5 19.5 6" FORK 7" FORK Lwer Leg Length Range Matrix 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. (12.11) QXi March 2015, MK-100024 REV B Page 5

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