a Mark Fr: Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Cnfirmatin Email: Cnfirm Via: Optin # ZIP: Submitting fr: Qute Order 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. HCPCS Definitin Quickie 5 R Price March 2018 EIR10 a 1. FRAME Optin # PO#: Ship T: Attentin: Address: Address: Ship T City: HCPCS ADDITIONAL SHIPPING INFORMATION ST: Definitin ZIP: Price 129WM86 129FA1 129FA8 129FA2 Base Mdel Frame Style (See Figure 3) Quickie 5 R (weight capacity 265 lbs) XTR Suspensin N/A with Xtender K0005 $2,325.00 Use E1236 fr sizes 14" r less 129FS34 Classic Frame 129FS35 Perfrmance Frame Frame Angle (see Figure 1) XTR Suspensin Frame Only 129FS36 75 available in Perfrmance Frame Set Up 80 129SK1 Light Shck (up t 180 lbs.) 85 129SK3 Heavy Shck (up t 265 lbs.) $895.00 129FF1 129FF2 129FF3 Frame Inset Per Side (See Figure 2) 0" 1" (N/A w/ 12" wide) 2" (N/A w/ 12", 13", r 14" wide) XTR available squeeze and RSH Frame Inset 0 1" 2" Ftrest Width Subtract 0 frm Frame Width Subtract 2" frm Frame Width Subtract 4" frm Frame Width Transit Transit nt available w/ XTR suspensin & Xtender. 129TO45 Transit System $320.00 129IN04 Attitude Bike (Optinal) Attitude Bike bundle See Order Frm Figure 1 Figure 2 Figure 3 Classic Frame - Traditinal seat sling t frnt frame bend angle dimensins. Perfrmance Frame - Seat Sling t frnt frame bend angle is 1.5" shrter than the classic psitin. Frnt f back cane pst t frnt edge f seat sling will remain the same fr bth Classic and Perfrmance. Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Page 1
2. SIZE / SEATING Depth Adjustable Backrest (Optinal) See diagram Depth Adjust Backrest extends the frame t the rear f the seat sling, select a factry setting. N/A n 19" and 20" Seat Depth r XTR frame. 129DP02 129DP03 129DP04 0 Setting Backrest at standard psitin, field adjustable t -1" r -2" -1 Setting Backrest -1" ffset, field adjustable t flush r -2" -2 Setting Backrest -2" ffset, field adjustable t flush r -1" $165.00 $165.00 $165.00 Seat Depth See Figure.1 Measures frm frnt f back pst t frnt edge f seat sling. Seat sling will be 1" shrter than depth rdered, but actual seat depth will remain the same as rdered. XTR frame N/A with 12 and 13 depth 129SD5 129SD6 129SD7 129SD8 129SD9 129SD10 129SD11 129SD12 129SD13 12" 13" 14" 15" 16" 17" 18" 19" E2203 20" $550.00 Seat Width See Figure 2. Measure frm utside f seat tube t utside f ppsite seat tube. XTR and J3 Back N/A w/ 12" and 13" widths 129S3 129S4 12" 13" 129S5 14" 129S6 15" 129S7 16" 129S8 17" 129S9 18" 129S10 19" 129S48 E2201 20" $500.00 129SL1 129SL6 129CU1 Seat Sling Standard Seat Sling Omit Seat Sling Cushin E0669 2" Cushin -$15.00 $120.00 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 129JC20 Cushin Name r Part # Price List Width: Depth: 3. CASTERS / SEAT HEIGHT Frnt Seat Height Caster Frk See Figures 4 and 5 129SH20 18.5" See Figures 5 and 6. Figure 6 in appendix pg 6. 129SH14 16.0" 129SH21 19.0" 129CF65 Multi Psitin Frk 129SH15 16.5" 129SH23 19.5" 129CF69 Single Side Frk $150.00 129SH16 17.0" 129SH24 20.0" 129SH17 17.5" 129SH26 20.5" 129SH18 18.0" 129SH27 21.0" Caster Frk Suspensin Frnt t Rear Seat Height Differences 129CF53 129CF54 129CF55 Frg Legs 0 weight t 100 lbs Frg Legs 101 lbs weight t 190 lbs Frg Legs 191 lbs weight t 265 lbs Frame Depth Max Seat Sqz 12"/13" 2.5" 14"/15" 3.0" Figure 4 16"/17" 3.5" 18"/19" 4.0" 20" 4.5" 129CW1 129CW3 129CW31 129CW72 129CW44 129CW64 129CW5 129CW51 129CW6 129CW65 129CW7 129CW66 129CW34 129CW35 129CW68 Caster Wheels 3" Micr 4" Lw Prfile Plyurethane 4" Micr Lighted $70.00 4" x 1" Aluminum Plyurethane $110.00 4" x 1.25" Semi Pneumatic $55.00 4" x 1.5" Aluminum Sft Rll $185.00 5" Lw Prfile Plyurethane 5" Micr Lighted $85.00 5" Sft Rll (Grey) N/A w/ Frg Legs 5"x 1" Aluminum Plyurethane $110.00 5"x 1.5" Semi Pneumatic $85.00 5"x 1.5" Aluminum Sft Rll $195.00 6" Plyurethane 6"x 1.5" Semi Pneumatic $85.00 6"x 1.5" Aluminum Sft Rll $205.00 Figure 5 Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Page 2
Rear Seat Height 4. REAR WHEELS / SEAT HEIGHT Rear Wheel Size Please reference RSH-Axle plate-wheel diagram n bttm f the page. Ultra Lightweight Wheels nly available with aluminum anndized handrim 129RH11 13.0" Cntact Built 4 Me fr Spinergy clr ptins 129RH12 13.5" 129RW103 20" Mag Wheel 5 Spke 129RH13 14.0" 129RW104 22" Mag Wheel 5 Spke 129RH14 14.5" 129RW102 24" Mag Wheel 5 Spke 129RH15 15.0" 129RW90 20" Lite Spke Wheel $200.00 129RH16 15.5" 129RW91 22" Lite Spke Wheel $200.00 129RH17 16.0" 129RW92 24" Lite Spke Wheel 129RH18 16.5" 129RW93 25" Lite Spke Wheel 129RH19 17.0" 129RW94 26" Lite Spke Wheel $80.00 129RH26 17.5" 129RW06 22" Ultra Lightweight Spke Wheel $250.00 129RH20 18.0" 129RW10 24" Ultra Lightweight Spke Wheel $250.00 129RH27 18.5" 129RW28 22" Spinergy SPOX Black 129RH21 19.0" 129RW95 24" Spinergy SPOX Black 129RH37 19.5" 129RW96 25" Spinergy SPOX Black 129RH22 20.0" 129RW97 129RW32 26" Spinergy SPOX Black 22" Spinergy LX Black Camber 129RW98 24" Spinergy LX Black 0,3,6 available with std frame. 0,4,8 available with XTR frame 129RW99 25" Spinergy LX Black 129CI1 0 129RW40 26" Spinergy LX Black 129CI2 3 129RW50 24" Muntain $250.00 129CI3 129CI4 4 6 Rear Wheel Tire 129CI5 8 See Availability Matrix n PAGE 4. 129RT1 Pneumatic 129XT6 E0986 22" Xtender Pwer Assist JWX-2 NICKEL $7,895.00 129XT7 E0986 22" Xtender Pwer Assist JWX-2 LITHIUM $8,695.00 129XT4 E0986 24" Xtender Pwer Assist JWX-2 NICKEL $7,895.00 129XT5 E0986 24" Xtender Pwer Assist JWX-2 LITHIUM $8,695.00 Please select ne f the fllwing handrim ptins 129XH5 Plastic Cated 129XH6 Stainless Steel 129XA10 129XA11 129XA9 E2213 Xtender Pwer Assist RSH 17.5"-19.5" with 22" wheels, RSH 18.5"-20" with 24" wheels 0 camber, N/A w/ Amputee Axle. 22" & 24" wheels nly. Nt available with XTR r standard rear suspensin. Anti-Tips n charge with Xtender. Dual Drive mde available w/b4me 129XA8 Xtender - Other Optins Spare NiMH Pwer Pack - NICKEL $1,395.00 Spare Li-in Pwer Pack - LITHIUM $1,795.00 Xtender Wheel Optins SPARE 22" Lite Spke Pneu Alum SPARE 22" Lite Spke Pneu Plastic See matrix figure 7 in appendix page 6 fr reference. 129HR22 129HR25 129HR23 129HR30 129HR31 129HR32 129HR26 129HR27 129HR28 129HR8 Handrim Plastic is nt available n all wheels in all sizes. Natural Fits available in 22" 24" and 25". Natural Fit 5 spke MAG nly in 24". Handrim Selectin N/A w/ Xtender. 129RT2 Pneumatic w/ Airless Insert E2213 N/A with Xtender $80.00 129RT3 Full Ply 129RT38 E2218 SHOX Perfrmance Ply 129RT39 High-Pressure Clincher Black 129RT21 Schwalbe Marathn Plus Evlutin $135.00 129RT27 Knbby V- Trak by Kenda 129RT12 Muntain Tire Only available in 24" 129HR1 129HR4 129HR24 129HR7 Aluminum Andized Plastic Cated N/A w/ 25" & 26" Lite Spke Wheels Natural Fit - Standard Grip $395.00 Natural Fit - N Thumb Grip $375.00 Natural Fit - Super Grip Natural Fit LT - Standard Grip $415.00 Natural Fit LT - Super Grip $475.00 Natural Fit LT - N Thumb Grip $375.00 The Surge - Oval w/griptin Strip $385.00 The Surge LT - Oval w/griptin Strip $415.00 Q-Grip Neprene Cated $325.00 Spinergy Flex Rim Only available n Spinergy LX wheels 24" & 25" $650.00 8 Oblique Prjectins N/A w/ SHOX tires, nly available with 24" Lite Spke Omit Handrim N/A w/ Ultra Lightweight Wheels $325.00 129XA2 SPARE 24" Lite Spke Pneu Alum 129XA4 E2213 SPARE 24" Lite Spke Pneu Plastic Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Page 3
4. REAR WHEELS / SEAT HEIGHT (CONT) 129AX1 129AX13 Axle Quick Release Steel Quad Quick Release Only available n 24" Muntain rear wheels $125.00 Rear Suspensin Rating Selectin nt required fr XTR Suspensin. N/A with Xtender 129SV04 Frm 0 weight t 100 lbs (Yellw) 129SV05 Frm 101 lbs weight t 190 lbs (Red) Axle Plates Selectin nt required fr XTR Suspensin Standard Shrt (COG 0.5" t 4") 129AL40 Sme limitatins with STFH Tire 129AL43 129AL100 129AL101 129AL38 129AL39 E0959 E0959 Standard Lng (COG 0.5" t 4") Axle plate amputee shrt Axle plate amputee lng Suspensin (COG -0.5 t +3) N/A with XTR Suspensin Frame 5 Spke Mag Xtender (COG 1"-4") Rear Tire & Wheel Matrix Lite Spke Pneumatic 20,22,24 20,22,24,26 22,24,26 Pneumatic w/ Airless Insert 20,22,24 20,22,24 22,24 Full Ply 20,22,24 20,22,24 Wheel Ultra Lightweight Spinergy SHOX Perfrmance Ply 20,22,24 20,22,24,25 24,25 High-Pressure Clincher Blk 22,24,26 24 22,24,26 Schwalbe Marathn 24,25,26 22 24,25,26 Knbby V Trak by Kenda 24 24 $175.00 $175.00 $395.00 Muntain Tire 24 20"= 451 mm 22" = 501 mm 24" = 540 mm 25" = 559 26" = 590mm Muntain Center f Gravity Measure frm frnt f back pst t center f rear axle. XTR Suspensin Frame will be factry set at 1.5", Xtender 1"- 4" 129CC29-1.5" 129CC11-1" 129CC10 -.5" 129CC12 0" 129CC1.5" 129CC2 1" 129CC3 1.5" 129CC4 2" 129CC5 2.5" 129CC6 3" 129CC7 3.5" 129CC8 4" Figure 9 5. WHEEL LOCKS Wheel Lck Nt all wheel lcks available in all seat depths, wheel sizes and COG settings. XTR suspensin nly available w/ high munt push 129WL46 129WL50 129WL68 High Munt Push High Munt Pull Erg Scissr 129WL64 Cmpact $125.00 129WL10 Omit Wheel Lck 129WL12 D Nt Munt Extensin Handle Only available w/ High Munt Push r Pull Wheel Lcks 129EH7 E0961 Extensin handles (Pair) $70.00 Grade Aid Only avail w/ high munt push r pull. N/A w/ clincher, ply, SHOX, Schwalbe, r Xtender 129GA1 E0974 Grade Aid $150.00 6. FOOTREST OPTIONS Ftrest Angle Adjustable Flip Back N/A w/ 19-20 wide & w/ 0 inset. Sme Flip back cnfiguratins wn't allw 2 " grund clearance and will need t raise up. Flip back nt available 1" inset & 5"- 6" casters. See matrix in Appendix 129F229 Aluminum Tubular 129F274 Aluminum Tubular w/ Snap On Cver $30.00 129F276 K0040 Angle Adjustable Flip Back $185.00 129F51 K0040 Aluminum Platfrm Ftrest 129F278 K0040 High Munt Platfrm Adaptive Platfrm Spacer Only available with Platfrm ftrest & Angle Adj. Flip Back. 129AD1 Adaptive Platfrm 2" Spacer 129AD2 Adaptive Platfrm 4" Spacer 129AD3 Adaptive Platfrm 6" Spacer 129DI03 129DI04 129DI05 129DI07 129DI02 129DI06 Ftrest Optins K0038 Leg Strap K0038 Extra Leg Strap Gel Hanger Cver Neprene Impact Guards Wear Pads K0038 Psitin Plates (N/A fr Tubular Ftrest) $35.00 $35.00 $105.00 $85.00 Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Page 4
7. BACKREST 129BT3 129BT82 129B110 129B127 129B111 129B137 129PH6 129PH5 129PH2 129JB01 Back Type Nn-Flding Angle Adjustable Flding w/ Duble Lck Dwn Angle Adj 129BU1 129BU88 129BU70 Back Uphlstery Standard Uphlstery Standard Uphlstery EXO Tensin Adj Ballistic Nyln E2611 *Reference 186BU70 fr billing Height Adjustable Backrest Tensin Adj 3DX Vented 129BU71 E2611 10 "- 14" Back Height *Reference 186BU71 fr billing $330.00 10 11 12 13 14 Backrest Tensin Adj EXO 129BU89 E2611 12 "- 16" Back Height *Reference XXXBU89 fr billing $330.00 12 13 14 15 16 129BU14 Omit Uphlstery (Use w/ JAY Backs) -$15.00 14 "- 18" Back Height 14 15 16 17 18 16 "- 20" Back Height Military Service Patches 16 17 18 19 20 Push Handles 129VU1 129VU2 129VU3 US Marines Patch US Army Patch US Navy Patch Integral Push Handles 129VU4 US Air Frce Patch Fld-Dwn Push Handles N/A w/ 10-129VU12 US Cast Guard $100.00 14" Back Height r Standard Uphlstery. 129VU5 Purple Heart Omit Push Handles 129VU8 Purple Heart with Marines Patch $145.00 129VU9 Purple Heart with Army Patch $145.00 JAY J3 Back 129VU10 Purple Heart with Navy Patch $145.00 JAY J3 Back See OF 129VU11 Purple Heart with Air Frce Patch $145.00 129VU13 Purple Heart with Cast Guard $145.00 8. ARMREST / SIDEGUARDS $315.00 Includes angle adj receiver hardware. Sme limitatins may exist w/ integral push handles, sme RSHs and wheel sizes 129AA18 E0973 Padded Swing-Away STD (9" t 14") $210.00 Setting 9" 10" 11" 12" 13" 14" 129AA11 129AA29 Armrest - Padded Swing Away Armrest - Height Adjustable E0973 Single Pst Ht. Adjust. Std (8.5"-13.5") E0973 Single Pst Ht. Adjust. Lw (7"-11") Armpad - Fr Height Adjustable Recmend using classic style fr tray tables 129AM23 129AM21 Desk Length (10") Classic Desk Length (10") Cntur 129AM24 129AM22 Full Length (14") Full Length (14") Classic Cntur $285.00 $285.00 Side Guards Sme interferance my exist w/ padded SA arms at lwest settings 129SG33 129SG29 Plastic - Standard Plastic - Lw $140.00 $140.00 Aluminum N/A w/ push, pull r cmpact 129SG35 wheel lck. N/A w/ XTR suspensin $235.00 129SG36 129SG12 129GE01 129GE02 129GE03 Aluminum w/ Fender N/A w/ push, pull r cmpact wheel lcks. N/A w/ XTR suspensin Carbn Fiber N/A w/ push, pull r cmpact wheel lcks Clr Fr Aluminum Side Guard Black Matching Frame - Standard Clrs Matching Frame - Custm Clr $245.00 $450.00 9. KEY OPTIONS AND ACCESSORIES Anti Tips Anti Tip Single Side N/A 12W-14W Anti Tip Single Side N/A with XTR, Xtender and Suspensin Axles. 129AT1 E0971 Anti Tips (Pair) $140.00 129AT3 Omit Rear Anti Tip 129AT14 E0971 Anti Tip Single Side - Flip Up $175.00 Left Right (Facing frm rear) 129A1 129A2 1291A01 Pack Accessries Black Utility Backpack Back Pack Black/Charcal Kids Seat Puch Black $65.00 $60.00 Spke Guards Only available with Lite spke. N/A w/ Xtender Pwer Assist 1294A01 K0065 Quickie Black Spke Guard 1294A02 K0065 Quickie Clear Spke Guard 129A2100 1298A22 1298A21 1298A05 E2207 Miscellaneus Crutch Hlder Only available with Integral r Fld Dwn push handle. Nt available with XTR Suspensin Blt-On Push Handles Tl Kit Gel-Pad swing away arm $115.00 $115.00 $195.00 $115.00 $45.00 $105.00 129A826 129A802 129A803 129A804 E0978 E0978 E0978 Psitining Belt Belt 1.5" Aut Buckle Universal Belt 2" Aircraft Buckle Belt 2" Aircraft Buckle Padded Psitining Belt Clamps Only $70.00 $110.00 $120.00 129A29 129A30 129A31 129A32 Upper Extremity Supprt Tray E0950 X-Small (Suggested fr 10"-12") $255.00 E0950 Small (Suggested fr 13"-14") $255.00 E0950 Medium (Suggested fr 15"-17") $255.00 E0950 Large (Suggested fr 18"-20") $255.00 Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Page 5
10. COLOR Standard Frame Clrs 129C140 Aztec Gld 129C2 Black (Nt avail as base w/zebra) 129C141 Black Cherry 129C10 Black Opal 129C38 Blue Opal 129C36 Candy Blue 129C14 Candy Purple 129C35 Candy Red 129C142 Electric Blue 129C143 Evergreen 129C44 Glssy White 129C126 Glw 129C144 Green Apple 129C147 Ht Sparkle Pink 129C148 Mauve Pink 129C103 Rtbeer 129C114 Sparkle Silver 129C145 Sunrise Orange 129C113 Titanium Clr Paint 129C8 Yellw Matte Frame Clrs 129C116 Matte Black 129C151 Matte Black Cherry 129C150 Matte Electric Blue 129C149 Matte Evergreen 129C152 Matte Purple Package includes nly frks, backcane bracket, axle sleeve clamp, ftrest clamp, Axle plate plug. Frg Legs, Xtender, suspensin axle plates black nly 129C112 129C43 129C42 129C108 129EB02 129EB06 129EB05 129EB04 129EB03 129EB01 129EB13 Custm Frame Clr Desert Camuflage Mssy Oak Camuflage Stars & Stripes Zebra (Chse abve base clr) Std with White unless abve base paint is chsen N/A w/ Blck, Matte Black, Blck Opal r Titanium) Andized Clr Package Black Blue Lime Green Purple Red Ti Grey Gld Built Fr Me T inquire abut any unique custmizatin fr Quickie prducts, cntact: Phne: (800) 333-4000, Optin #3, Fax: (800) 333 9011 11. APPENDIX Figure 6 Handrims 5 Spke Mag Figure 7 Lite Spke Wheels Ultra Lightwght Spinergy LX Spinergy SPOX Muntain Aluminum Andized 20,22,24 20,22,24,25,26 22,24 22,24,25,26 22,24,25,26 24 Plastic Cat 20,22,24 22,24 N/A 24,25,26 24,25,26 24 Natural Fit - Standard Grip 24 22,24,25,26 N/A 22,24,25,26 22,24,25,26 N/A Natural Fit - N Thumb Grip 24 22,24,25,26 N/A 22,24,25,26 22,24,25,26 N/A Natural Fit - Super Grip 24 22,24,25,26 N/A 22,24,25,26 22,24,25,26 N/A Natural Fit LT - Std Grip 24 22,24,25,26 N/A 22,24,25,26 22,24,25,26 N/A Natural Fit LT - Super Grip 24 22,24,25,26 N/A 22,24,25,26 22,24,25,26 N/A Natural Fit LT - N Thumb Grip 24 22,24,25,26 N/A 22,24,25,26 22,24,25,26 N/A Surge - Oval w/griptin Strip N/A 22,24,25,26 N/A 22,24,25,26 22,24,25,26 N/A Surge LT - Oval w/griptin Strip N/A 22,24,25,26 N/A 22,24,25,26 22,24,25,26 N/A Q Grip Neprene Cated N/A 24,25 N/A 24,25 24,25 N/A Spinergy Flex Rim N/A N/A N/A 24,25 N/A N/A 8 Oblique Prjectin N/A 24 N/A N/A N/A N/A Omit Handrim 20,22,24 N/A N/A 22,24,25,26 22,24,25,26 24 Sunrise Medical (US) LLC 2842 Business Park Ave. Fresn, CA 93727 USA Custmer Service: 800-333-4000 Fax: 800-300-7502 Email: rders@sunmed.cm www.sunrisemedical.cm Page 6