a Mark Fr: Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Address: Fax: ( ) Cnfirmatin Email: Cnfirm Via: ZIP: Quickie QXi Nvember 2012 EIF6 Submitting fr: Ship T: Address: Ship T City: Qute 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. Optin # HCPCS a Definitin Price Optin # HCPCS Definitin Price 1. FRAME STYLE & SETUP PO#: Attentin: ST: Order ADDITIONAL SHIPPING INFORMATION ZIP: 196WM78 Base Mdel Quickie QXi (265 lbs) K0005 Fr 14" sizes use E1236 Frame Style See Seat Height Matrix n page 2 196FS9 Standard Frame 196FS30 Hemi Frame $1,845.00 Frame Width 196W5 14" 196W6 15" 196W7 16" 196W8 196W9 196W10 196W11 E2201 20" $450.00 Transit 196TO38 Transit System 14" $315.00 196SD7 196SD8 196SD9 196SD10 196SD11 196SD71 196SD13 E2203 15" 16" 17" 20" Seat Depth $475.00 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 January 2012, 118441 REV. D 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" 3.5" FORK 5 1/4" FORK 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" 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" 15.0 15.5 13.0 13.5 16.5 17.5 14.5 15.5 196SH23 19.5" 6 Ply Wheels 8 Ply N/A N/A N/A N/A 19.0 19.0 17.0 17.0 196CW3 4" Lw Prfile Plyurethane 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 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 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) 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 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 196H139 196H141 60 Swing In/Out Hanger 70 Swing In/Out Hanger 80 Swing In/Out Hanger 196H143 E0990 Elevating Legrest (Frnt Latch) All ELR's will be Black paint $295.00 196H144 Omit Hanger & Ftplate Extensin Tubes See Lwer Leg Length Matrix fr range 196E1 196E2 196E5 Shrt Medium Lng Ftplate Heel lp nt included, see Ftplate Optin sectin belw 196F1 196F3 K0040 Cmpsite Ftplate Aluminum Angle Adj. Ftplate 196F5 Aluminum Only available w/elevating Legrest $185.00 Lwer Leg Length Range Matrix Hanger Ext Tube Ftplate Cmpsite Alum Angle Adj Aluminum Shrt 11.25" - 14.75" 9.25" - 13.25" NA 60 Medium 11.25" - 16.00" 9.25" - 14.75" NA Lng 12.50" - 16.00" 10.75" - 16.25" NA Shrt 12.00" - 15.75" 10.00" - 14.50" NA 70 Medium 12.00" - 16.50" 10.75" - 16.50" NA Lng 13.75" - 16.50" 12.25" - 16.50" NA Shrt 10.50" - 15.25" 10.50" - 15.25" NA 80 Medium 11.75" - 16.50" 11.75" - 16.50" NA Lng 13.50" - 16.50" 11.75" - 16.50" NA Shrt 11.25" - 15.50" 11.00" - 14.50" 11.50" - 16.50" ELR Medium 12.50" - 16.50" 11.25" - 16.25" 13.50" - 16.50" Lng 14.50" - 16.50" 13.00" - 16.50" 15.25" - 16.50" All values are ± 0.25" and based n flat seat heights and d nt accunt fr the minimum 2" grund clearance r ftplate thickness. Full ELR values based n 70 hanger angle 196HL12 1968A02 Hanger & Ftplate Optins E0951 Adjustable Heel Lp Gel Cver Fr Hangers (Pair) $35.00 $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 January 2012, 118441 REV. D Page 2
4. REAR SEAT HEIGHT SET UP Rear Seat Height Matrix 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 Wheel Size See Rear Tire & Wheel Matrix fr availability 196RW3 20" Mag Wheel 196RW8 22" Mag Wheel 196RW1 24" Mag Wheel 196RW90 20" Lite Spke Wheel 196RW91 22" Lite Spke Wheel 196RW92 24" Lite Spke Wheel 196RW100 25" Lite Spke Wheel 196RW101 26" Lite Spke Wheel 196RW25 Omit Hemi Frame 12.0" - 15.0" 12.5" - 16.0" 13.5" - 17.0" 14.0" - 17.5" 14.5" - 18.0" Rear Seat Height See Rear Seat Height Matrix 12" 196RH9 12.5" 196RH10 13" 196RH11 13.5" 196RH12 14" 196RH13 14.5" 196RH14 15" 196RH15 15.5" 196RH16 16" 196RH17 16.5" 196RH18 17" 196RH19 17.5" 196RH26 196RH20 18.5" 196RH27 196RH21 Seat Squeeze Matrix Fram e Depth Max Seat Squeeze 14" 2.0" 15" - 16" 2.5" 17" - 2.5" - 20" 3.0" Rear Wheel Tire See Rear Tire & Wheel Matrix fr availability 196RT1 Pneumatic E2212 196RT2 Pneumatic w/ Airless Insert E2213 E2218 Full Ply 196RT3 196RT6 High-Pressure Clincher E2212 $80.00 $95.00 Handrim Natural Fit nly available w/ 22, 24, 25 Lite Spke. Plastic NA w/ 25, 26" Aluminum Andized 196HR1 Plastic $95.00 196HR4 Natural Fit - Standard Grip $375.00 196HR22 Natural Fit - Super Grip $395.00 196HR23 196WL1 196WL2 196WL30 196WL10 196WL12 Wheel Lck High Munt Push High Munt Pull Cmpact Omit Wheel Lck D Nt Munt Rear Tire & Wheel Matrix Wheel Mag Tire Pneumatic Pneumatic w/ Airless Insert Full Ply Tire 20,22,24 High Pressure Clincher N/A 22" = 489 mm 24" = 540 mm Extensin Handle Ext. handles nly available with high munt push r pull wheel lcks E0961 Extensin Handle (Pair) 196EH7 Spke 20,22,24 22,24,25,26 196AX1 196AX11 Axle Quick Release Steel Quad Quick Release Steel NA n Spke $60.00 5. ARMREST Armrest - Padded Swing Away 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 196AA18 196AA104 196AA105 196AA65 196AA14 196AA98 E0973 Padded Swing-Away (9" t 13") Setting 9" 10" 11" 12" Armrest - Height Adjustable E0973 Single Pst Ht. Adj - Std (9.75"-14.75") E0973 Single Pst Ht Adj - Lw (8.25"-12.25") E0973 Flip Back Ht Adj LITE (10"-15") Omit Armrest E0973 Dual Pst Flip Back Ht Adj 196AM23 196AM24 1968A01 $175.00 13" Armpad - Fr Height Adjustable Desk Length (10") Full Length - Full (14") Armrest Optins Gel Cver Fr Swing Away Arms (pair) $260.00 $260.00 $275.00 $275.00 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 January 2012, 118441 REV. D Page 3 $110.00
6. BACKREST 196BT10 196BT100 196B5 196B9 196PH6 Back Type Standard Angle Adjustable Back Backrest Height Med (13"-17") Tall (16"-20") Push Handles Integral Push Handles 8 fr Std Backrest, Straight fr Angle Adj. Backrest $165.00 196PH5 196PH2 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 196BU1 196BU70 196BU71 196BU14 196JB01 Back Uphlstery Standard Uphlstery Backrest Tensin Adj Ballistic Nyln E2611 *Reference 186BU70 fr billing Backrest Tensin Adj 3DX Vented E2611 *Reference 186BU71 fr billing Omit Back Uphlstery JAY J3 Back JAY J3 Back $315.00 $330.00 -$15.00 See OF Fld-Dwn Push Handles $100.00 Military Service Patches Only available n tensin adjustable uphlstery and Jay 3 Back 196VU1 US Marines Patch 196VU2 US Army Patch 196VU3 US Navy Patch 196VU4 US Air Frce Patch 196VU12 US Cast Guard 196VU5 Purple Heart 196VU8 Purple Heart with Marines Patch 196VU9 Purple Heart with Army Patch 196VU10 Purple Heart with Navy Patch 196VU11 Purple Heart with Air Frce Patch 196VU13 Purple Heart with Cast Guard 7. SEATING 196SL23 196SL6 Seat Sling Seat Sling Depth Adjustable Omit Seat Sling JAY Cushins (Optinal) -$15.00 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 JAY Bundled Cushin 196JC20 Cushin Name r Part # Price List Width: Depth: 8. Key Optins & Accessries 196AT1 196SG33 196SG29 196A1 1961A01 196A141 196A804 Anti Tips E0971 Anti Tips (Pair) $135.00 1964A01 Spke Guards K0065 Quickie Black Spke Guard $115.00 Side Guards K0108 Plastic - Standard (8.5" High) K0108 Plastic - Lw (6.5" High) 1968A03 196A2100 Miscellaneus Caddy E2207 Crutch Hlder $45.00 $195.00 $55.00 $45.00 196C2 196C10 196C38 196C36 196C35 Pack Accessries Backpack - Black/Charcal Adult Seat Puch Black Psitining Belt E0978 1.5" Aut Buckle w/ Clamps K0108 Psitining Belt Slide Clamps $70.00 $50.00 Frame Clr Black Black Opal Blue Opal Candy Blue 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 January 2012, 118441 REV. D Page 4
Frnt Seat Height Matrix Cnt. 3/4" STEM 3.5" FORK 5 1/4" FORK 4 Lw Ply 5 Lw Ply 6 Ply 1 1/2" STEM 3.5" FORK 5 1/4" FORK 4 Lw Ply 5 Lw Ply 6 Ply N/A N/A N/A N/A 18.5 19.5 16.5 17.5 8 Ply 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 N/A N/A N/A N/A 19.5 19.5 17.5 18.0 N/A N/A N/A N/A 17.0 18.0 14.5 15.5 6" FORK 7" FORK N/A N/A N/A N/A 18.0 19.0 16.0 17.0 N/A N/A N/A N/A 18.0 19.0 16.0 17.0 N/A N/A N/A N/A 18.5 19.5 16.5 17.5 6" FORK 7" FORK 4 Lw Ply 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 19.0 19.5 17.0 17.5 N/A N/A 17.5 18.5 5 Lw Ply 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 19.0 19.5 17.0 18.0 N/A N/A 18.0 19.0 6 Ply 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 8 Ply 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 N/A N/A 18.0 19.0 N/A N/A 18.5 19.5 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 January 2012, 118441 REV. D Page 5