Quickie QXi SUBMIT August 2016 EIF6 Mark Fr: Submitting fr: Date: PO#: Qute Order Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFORMATION Dealer Cntact: Ship T: Dealer Address: Attentin: Dealer City: ST: Dealer Phne: ( Cnfirmatin Email: Fax: ( Address: Ship T City: Fax Cnfirm Via: Address: ZIP: Email ST: Ship T Phne: ( ZIP: 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. a Optin # HCPCS Definitin Price a Optin # HCPCS Definitin Price 1. FRAME 196WM78 K0005 Base Mdel Quickie QXi (Adjustable Axle 265 lbs Fr sizes use E1236 $1,845.00 Frame Style See Seat Height Matrix n page 2 196FS9 Standard Frame 196FS30 Hemi Frame 196TO38 Transit Transit System WC19 2. SIZE / SEATING Frame Width 196W5 196W6 196W7 196W8 196W9 196W10 196W11 E2201 20" 196SL1 196SL6 Seat Sling Standard Seat Sling Omit Seat Sling 196QC01 196QC02 196QC03 Custm Seating Surefit Cnfigurfit JayFit Quickie QXi, Ultra Lightweight Adjustable Flding Wheelchair $500.00 -$15.00 Seat Depth Frame Depths equals Seat Depths. 196SD7 196SD8 196SD9 196SD10 196SD11 196SD71 196SD13 E2203 20" $550.00 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: 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., MK-100024 REV D Page 1
3. CASTERS / SEAT HEIGHT Frnt Seat Height See Frnt Seat Height Matrix. 12.5 & 13.0 nly available w/ 60 hanger 1 & 13" nly available w/ Alum Angle Adj Ftplate 196SH34 1 196SH14 16.0" 196SH35 13.0" 196SH15 16.5" 196SH40 13.5" 196SH16 17.0" 196SH41 14.0" 196SH17 17.5" 196SH42 14.5" 196SH18 18.0" 196SH12 15.0" 196SH20 18.5" 196SH13 15.5" 196SH21 19.0" 196SH23 19.5" 196CW3 196CW44 196CW5 196CW7 196CW34 196CW35 196CW32 196CW39 Caster Wheels 4" Lw Prfile Plyurethane 4" x 1.25" Semi Pneumatic 5" Lw Prfile Plyurethane 5" x 1.5" Semi Pneumatic 6" Plyurethane 6" x 1.5" Semi Pneumatic 8" Plyurethane 8" x 1.5" Semi Pneumatic 196CF71 196CF12 196CF17 196CF23 Caster Frk 3.5" (standard stem blt nly 5.25" 6" 7" Caster Stem Blt Standard 3/4" 1 1/2" 196CS1 196CS5 196CS9 Frnt Seat Height Matrix $55.00 4. REAR WHEELS / REAR SEAT HEIGHTS Rear Seat Height See Rear Seat Height Matrix 12" 196RH9 1 196RH10 13" 196RH11 13.5" 196RH12 196RH13 14.5" 196RH14 196RH15 15.5" 196RH16 196RH17 16.5" 196RH18 196RH19 17.5" 196RH26 196RH20 18.5" 196RH27 196RH21 Rear Wheel Size See Rear Tire & Wheel Matrix fr availability 196RW3 20" Mag Wheel 196RW8 22" Mag Wheel 196RW1 24" Mag Wheel 196RW103 20" Mag Wheel 5 Spke 196RW104 22" Mag Wheel 5 Spke 196RW102 24" Mag Wheel 5 Spke 196RW90 20" Lite Spke Wheel 196RW91 22" Lite Spke Wheel 196RW92 24" Lite Spke Wheel 196RW93 25" Lite Spke Wheel 196RW94 26" Lite Spke Wheel 196RW25 Omit Rear Wheel Size 20" Rear Wheel 22" Rear Wheel 24" Rear Wheel 25" Rear Wheel 26" Rear Wheel Rear Seat Height Matrix Std Frame 13.0" - 16.5" 14.0" - 17.5" 15.0" - 18.5" 15.5" - 19.0" 16.0" - 19.5" Hemi Frame 12.0" - 15.0" 1-16.0" 13.5" - 17.0" 14.0" - 17.5" 14.5" - 18.0" Rear Wheel Tire See Rear Tire & Wheel Matrix fr availability 196RT1 Pneumatic 196RT2 Pneumatic w/ Airless Insert E2213 E2218 Full Ply 196RT3 196RT39 High-Pressure Clincher Black 196RT21 Schwalbe Marathn Plus Evlutin Handrim Natural Fit nly available w/ 22, 24, 25 Lite Spke. Plastic NA w/ 25, 26" See Apendix fr Rear wheel / Handrim matrix Aluminum Andized 196HR1 Plastic 196HR4 Natural Fit - Standard Grip 196HR22 Natural Fit - Super Grip 196HR23 Natural Fit - N Thumb Grip 196HR32 The Surge - Oval w/griptin Strip 196HR26 The Surge LT - Oval w/griptin Strip 196HR27 Q-Grip Neprene Cated 196HR28 Seat Squeeze Matrix Max Seat Squeeze Fram e Depth 2.0" - - - 20" 3.0" 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., MK-100024 REV D Page 2 $80.00 $95.00 $95.00 $410.00 $395.00
4. REAR WHEELS / REAR SEAT HEIGHTS (CONT Rear Tire & Wheel Matrix 196AX1 196AX11 196AX45 196AS4 196AS5 196AS6 Axle Quick Release Steel Quad Quick Release Steel NA n Spke Threaded Axle $100.00 Adjustable Axle Optins Adjustable sleeve Fixed Sleeve 0⁰ Fixed Sleeve 3⁰ Center f Gravity Measure frm frnt f back pst t center f rear axle 196CC2 1" 196CC3 1.5" 196CC4 2" 196CC5 196CC6 3" 5. WHEEL LOCKS 196WL1 196WL2 196WL30 196WL24 196WL23 196WL10 196WL12 Wheel Lck High Munt Push High Munt Pull Cmpact Unilateral Wheel Lck Right Unilateral Wheel Lck Left Omit Wheel Lck D Nt Munt $300.00 $300.00 Extensin Handle Ext. handles nly available with high munt push r pull wheel lcks E0961 Extensin Handle (Pair 196EH7 $65.00 6. HANGERS AND FOOTRESTS 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 Articulating Hanger K0053 NA w/ Alum Angle Adj Frnt Munt $350.00 ftplates. 196H160 Elevating Hanger - Ext Munt E0990 NA w/ Alum Angle Adj Frnt Munt ftplates. 196H161 Elevating Hanger - Frnt Munt E0990 Only available w/ frnt munt alum angle adj ftplates and -22" width 196H144 Omit Hanger & Ftplate Extensin Tubes See Lwer Leg Length Matrix fr range 196E1 Shrt 196E2 Medium 196E5 Lng Ftplate Heel lp nt included, see Ftplate Optin sectin belw 196F1 Cmpsite Ftplate K0040 196F271 Cmpsite Angle Adj (-22"w E0951 196F3 K0040 Aluminum Angle Adj. Ftplate Aluminum 196F5 Only available w/elevating Legrest $150.00 $185.00 196HL12 1968A02 Hanger & Ftplate Optins E0951 Adjustable Heel Lp Gel Cver Fr Hangers (Pair $35.00 $110.00 7. BACKREST / SEATING 196BT10 196BT100 196B5 196B9 Back Type Standard Angle Adjustable Back Backrest Height Med (13"- Tall (-20" $165.00 Push Handles Integral Push Handles, Flding Height Adjustable & Omit is 8 fr Standard Backrest, Straight fr Angle Adj. Backrest 196PH6 Integral Push Handles Fld-Dwn Push Handles 196PH5 196PH17 196PH2 Only available with Adjustable Uphlstery. Used in cmbinatin w/angle Adjust nly avail in -20" back height Flding Push Handle with Ht. Adj. Back Omit Push Handles 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., MK-100024 REV D Page 3 $100.00 $225.00
7. BACKREST / SEATING (CONT 196BU1 196BU88 196BU70 196BU71 196BU89 196BU14 196JB01 Back Uphlstery Standard Uphlstery Standard Uphlstery EXO Backrest Tensin Adj Ballistic Nyln *Reference 186BU70 fr billing Backrest Tensin Adj 3DX Vented *Reference 186BU71 fr billing Backrest Tensin Adj EXO *Reference XXXBU89 fr billing Omit Back Uphlstery $50.00 $330.00 $330.00 -$15.00 JAY Backs JAY Back (see Order frms Price List 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 8. ARMREST / SIDEGUARDS 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 Padded Swing-Away STD (9" t 13" Setting 9" 10" 11" 12" Armpad - Fr Height Adjustable Desk Length (10" Full Length - Full ( 196AM23 196AM24 1968A01 196SG33 196SG29 Side Guards K0108 Plastic - Standard (8.5" High K0108 Plastic - Lw (6.5" High 1964A01 1964A02 Spke Guards K0065 Quickie Black Spke Guard K0065 Quickie Clear Spke Guard $115.00 $115.00 1968A03 196A2100 Miscellaneus Caddy E2207 Crutch Hlder $45.00 $195.00 $210.00 13" Armrest - Height Adjustable Armrest Optins Gel Cver Fr Swing Away Arms (pair $110.00 Flip Back HA Classic NA w / - depth 196AA104 196AA105 196AA65 196AA103 196AA159 196AA14 Single Pst Ht. Adj - Std (9.75"-14.75" Single Pst Ht Adj - Lw (8.25"-12.25" Flip Back Ht Adj LITE (10"- Dual Pst Flip Back Ht Adj Flip Back Ht Adj Classic (11"- Omit Armrest $285.00 $285.00 9. KEY OPTIONS 196AT1 196A1 1961A01 196A141 196A804 Anti Tips E0971 Anti Tips (Pair Pack Accessries Backpack - Black/Charcal Adult Seat Puch Black Psitining Belt E0978 1.5" Aut Buckle w/ Clamps K0108 Psitining Belt Slide Clamps $140.00 $55.00 $45.00 $70.00 $50.00 10. COLOR 196C140 196C2 196C141 196C10 196C38 196C36 196C14 196C35 196C142 196C143 196C126 196C144 196C147 196C148 196C103 196C114 196C145 196C113 196C8 Standard Frame Clrs Aztec Gld Black (Nt avail as base w/zebra Black Cherry Black Opal Blue Opal Candy Blue Candy Purple Candy Red Electric Blue Evergreen 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 196C116 196C151 196C150 196C149 196C152 196C112 196C43 196C42 Custm Frame Clr Desert Camuflage Mssy Oak Camuflage Stars & Stripes Zebra (Chse abve base clr Std 196C108 with White unless abve base paint is chsen NA w/ Blk, Matte Black, Blk Opal, Titanium Additinal Optins Thrugh Built fr Me T inquire abut any unique custmizatin fr Quickie prducts, cntact: Phne: (800 333-4000, Fax: (800 333 9011 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., MK-100024 REV D Page 4
APENDIX Frnt Seat Height Matrix Cnt. 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., MK-100024 REV D Page 5