Quickie 2 Lite Order Form (rev. L)

Transcript

Quickie 2 Lite January 2014 SUBMIT EIQ2N Mark For: Submitting for: Date: PO#: † Quote † Order Dealer Acct #: Dealer: ADDITIONAL SHIPPING INFORMATION Dealer Contact: Ship To: Dealer Address: Attention: Dealer City: ST: Dealer Phone: ( Confirmation Email: ) Fax: ( Address: ) Ship To City: † Fax Confirm Via: Address: ZIP: † Email ST: Ship To Phone: ( ) ZIP: Fax: ( ) The HCPCS CODES provided are based on code verification through PDAC or our interpretation of the code definitions. The use of HCPCS CODES does not ensure coverage or payment. For coverage information, verify the appropriate payer's coverage policy. D Option # HCPCS Definition D Price Option # HCPCS Definition Price 1. FRAME STYLE & SET UP E1236 coding still applies for EIQ2N with certain sizes 184WM58 K0005 Quickie 2 Lite † See FIGURE 1 and Seat Squeeze Matrix Measured from back canes to front edge of upholstery. Frame Style See FIGURE 1 Measure from front frame to floor † Seat Depth $2,050.00 184SD67 15" NC 184SD9 16" NC 184SD69 17" NC NC † NC † † NC † 184FS32 Fixed Front 70 † 184FS33 Fixed Front 80 o NC 184SD7 Swing Away Frame o 14" Front of seat sling 2" behind front edge of frame. † 184FS31 Frame Inset (Fixed Front Only) † 184SD70 18" NC See FIGURE 2 Frame inset is the distance from the outside of the seat tube to the outside of the footrest. Footrest width = frame width minus 2. † 184FF1 NC 0" † † 184SD71 184SD13 19" E2203 20" $75.00 $475.00 † 184FL83 Small † 184FL9 Regular 14"-16", Fixed 15"-16" NC Frame Width † 184FL18 Long 17"-18" NC See FIGURE 2 Measured from outside of seat tube to the outside of opposite seat tube. NC 184W5 14" † NC 184W6 15" † NC 184W7 † 16" NC 184W8 † 17" NC 184W9 † 18" NC 184W10 † 19" $450.00 E2201 20" 184W11 † † 184FL25 X-Long 19"-20" NC † 184FF2 1" NA for 14" and 15" Wide using composite footrest Figure 1 NC Frame Length Fixed front only 14"-16" Seat Squeeze Matrix Seat Depth 14"-15" 16"-19" 20" Max Seat Squeeze 2.0" 2.5" 3.0" Figure 2 Customer Service: 800-333-4000 Fax: 800-300-7502 Email: [email protected] www.sunrisemedical.com Specifications are subject to change without notice. Copyright © 2012 Sunrise Medical (US) LLC. (11.05) Quickie 2 Lite 108610 REV. L Page 1 NC 2. FRONT SEAT HEIGHT SET UP Front Seat Height Caster Wheels † 184SH42 14.5" (Only available on Fixed Front) NC † † 184SH12 15" (Only available on Fixed Front) NC † 184SH13 15.5" (Only available on Fixed Front) † 184SH14 16" (Only available on Fixed Front) † 184SH15 16.5" † 184SH16 † 184SH17 NC † 184CW1 184CW3 3" Micro 4" Low Profile Polyurethane NC † 184CW31 4" Micro Lighted $70.00 NC † 184CW72 4" x 1" Aluminum Polyurethane $80.00 NC † 184CW44 4" x 1.25" Semi Pneumatic 17" NC † 184CW64 4" x 1.5" Aluminum Soft Roll 17.5" NC † 184CW5 5" Low Profile Polyurethane † NC $55.00 $155.00 NC † 184SH18 18" NC 184CW51 5" Micro Lighted † 184SH20 18.5" NC † 184CW65 5" x 1" Aluminum Polyurethane † 184SH21 19" NC † 184CW7 5" x 1.5" Semi-Pneumatic $85.00 † 184SH23 19.5" NC † 184CW6 $85.00 20" (Max length for fixed front) NC † 184SH24 5" Soft Roll (Grey) NA w/ Frog Legs † 184SH26 20.5" (Only available on swing away) NC † 184CW66 5" x 1.5" Aluminum Soft Roll † 184SH27 21" (Only available on swing away) NC † 184CW34 6" Polyurethane Caster Housing † † NC 184CP11 Standard 184CP12 Hemi Subtract 1 3/4 " from Standard Front STFH Matrix NC E2214 6" Pneumatic E2215 $85.00 $100.00 $165.00 NC † 184CW33 † 184CW35 6" x 1.5" Semi Pneumatic † 184CW68 6" x 1.5" Aluminum Soft Roll † 184CF46 Short Fork NC † 184CF45 Short Wide Fork Used with 1.25" or 1.5" wide caster NC $75.00 $85.00 $180.00 Caster Fork Front Seat Height Matrix Standard Caster Housing (For Hemi Housing Subtract 2") 6" 5" 4" 3" Caster Size Short Spacer Front Height SA Front Frame Front Height Fixed Front Frame 16 1/2 15 1/2 17 16 17 1/2 16 1/2 18 18 1/2 17 17 1/2 19 18 19 1/2 18 1/2 17 17 1/2 16 16 1/2 None +.5" Short Wide +1" None Fork Hole +.5" Tall Wide +1" None Fork Hole +.5" Frog Legs +1" None Fork Hole Fork Hole Top Bottom Top Top Middle Bottom Bottom Top Middle Bottom Top Middle Middle Bottom 17 17 1/2 18 19 1/2 18 1/2 20 19 18 18 1/2 17 17 1/2 19 18 19 1/2 18 1/2 20 20 1/2 19 19 1/2 19 18 19 1/2 18 1/2 20 20 1/2 19 19 1/2 21 20 Top Bottom Middle Top Bottom Bottom Top Middle Bottom 184CF53 † † Tall Wide Fork $425.00 184CF54 E1015 Frog Legs Suspension (101-190 lbs) $425.00 184CF55 E1015 Frog Legs Suspension (191-265 lbs) $425.00 Caster Options Top † 184OC1 Caster Pin Locks NA w/ hemi caster housing, frog legs, short wide fork Top Top Middle Middle Bottom Bottom Top Top Middle Top Middle Bottom Middle Bottom Bottom Top Middle Bottom Top Middle Bottom Bottom Middle Bottom Bottom Bottom Top Middle Bottom Middle Middle Bottom Bottom Top Middle Top Middle Bottom Middle Bottom Bottom Middle Bottom Middle Bottom Bottom Middle Bottom Bottom Bottom Middle Bottom NC E1015 Frog Legs Suspension (0-100 lbs) Middle Top Top 184CF32 † Top Middle Bottom Bottom Bottom ✘ † Top Bottom 18 1/2 19 +1" Top Bottom 18 +.5" Middle Bottom Bottom Bottom Bottom Customer Service: 800-333-4000 Fax: 800-300-7502 Email: [email protected] www.sunrisemedical.com Specifications are subject to change without notice. Copyright © 2012 Sunrise Medical (US) LLC. (11.05) Quickie 2 Lite 108610 REV. L Page 2 $195.00 3. HANGER & FOOTPLATE OPTIONS Swing - Away Hangers Footplates Footplate mounts with Extension Tube using clamping hardware Heel loop or leg strap not included, See Footplate Options Section 184F1 Composite (13"-22"w) † † 184H86 70° Swing In/Out Hanger NC † 184H116 80° Swing In/Out Hanger NC † † 184H32 Omit Hanger and Footplate -$15.00 † 184F3 K0040 Aluminum Angle Adj (16"-22"w) $185.00 † 184F48 K0040 Platform Flip Up $190.00 † 184F245 K0040 Tubular Flip Up Fixed front frame only $100.00 † 184F250 K0040 Auto Fold Angle Adj Fixed front frame only $200.00 † 184HL1 E0951 Heel Loop $30.00 † 184HL5 K0038 Leg Strap $35.00 Footrest Extension Tubes See Extension matrix for leg length range † 184E1 Short NC † 184E2 Medium NC † 184E5 Long NC 184F271 NC $150.00 K0040 Composite Angle Adj (16"-22"w) Footplate Options Swing Away Fixed Front Footrest Type and Extension Composite/ Tubular/ Platform Aluminum Autofold Inset Footrest Angle Frame Type Extension Matrix Short Min 0° Max 70° Min 1° Max Min 0° Max 80° Min 1° Max Min 70° Std Max Min 80° Std Max 13 17 13 17 14 17 14 17 11 15 11 14 3/4 1/2 3/4 1/2 1/2 1/2 1/2 1/2 1/4 1/4 1/2 3/4 Med 13 3/4 19 1/2 15 19 1/2 14 1/2 19 1/2 15 19 1/2 12 1/4 17 12 1/4 16 3/4 Long Short Long Short Long 14 3/4 20 1/2 16 1/4 20 1/2 15 1/2 21 1/2 17 21 1/2 13 1/4 18 1/4 14 18 1/2 13 1/2 16 1/2 13 1/2 16 1/2 14 3/4 18 14 3/4 18 11 1/4 14 1/4 11 3/4 15 15 1/4 21 16 3/4 21 16 1/2 22 1/2 18 22 1/2 13 3/4 18 3/4 15 19 1/2 12 16 1/2 12 16 1/2 13 17 3/4 13 17 3/4 10 14 1/4 10 1/4 14 3/4 12 1/4 18 13 1/2 18 13 1/4 19 1/4 14 1/2 19 1/4 10 3/4 15 3/4 11 3/4 16 1/4 Lower Leg Length Setting Recommend 2" footrest clearance to ground surface ✘ † 184LO07 12.0" NC † 184LO16 16.5" NC † 184LO08 12.5" NC † 184LO17 17.0" NC † 184LO09 13.0" NC † 184LO18 17.5" NC † 184LO10 13.5" NC † 184LO19 18.0" NC † 184LO11 14.0" NC † 184LO20 18.5" NC † 184LO12 14.5" NC † 184LO21 19.0" NC † 184LO13 15.0" NC † 184LO22 19.5" NC † 184LO14 15.5" NC † 184LO23 20.0" NC † 184LO15 16.0" NC † 184LO24 20.5" NC Customer Service: 800-333-4000 Fax: 800-300-7502 Email: [email protected] www.sunrisemedical.com Specifications are subject to change without notice. Copyright © 2012 Sunrise Medical (US) LLC. (11.05) Quickie 2 Lite 108610 REV. L Page 3 4. REAR SEAT HEIGHT SET UP Rear Seat Height 13" & 13.5" NA w/ transit 184RH11 13.0" † Rear Seat to Floor Height Matrix NC † 184RH18 16.5" NC Note: These values are representative of a 16" seat depth with 1" of seat squeeze and standard axle plate. Due to variances caused by seat angle, rear seat height ranges may shift up or down by as much as 1/2". Call customer service or online configurator for more information. † 184RH12 13.5" NC † 184RH19 17.0" NC † 184RH13 14.0" NC † 184RH26 17.5" NC † 184RH14 14.5" NC † 184RH20 18.0" NC † 184RH15 15.0" NC † 184RH27 18.5" NC 20" All † 184RH16 15.5" NC † 184RH21 19.0" NC 22" Poly NA NA † 184RH17 16.0" NC † 184RH37 19.5" NC 22" Pneu NA NA NA 24" Pneu X X X X X X X X X X X X X X X X X X X X X X NA NA NA NA X X X X X X X X NA NA 24" All but Pneu NA NA NA NA X X X X X X X X NA NA 25" Kik NA NA NA NA X X X X X X X X NA NA NC 25" All but Kik NA NA NA NA NA X X X X X X X X NA 26" All NA NA NA NA NA NA X X X X X X X X Rear Wheel Type See availability matrix. Contact Built 4 Me for Spinergy color options † 184RW3 20" Mag Wheel † 184RW8 22" Mag Wheel NC † 184RW1 24" Mag Wheel NC † 184RW90 20" Lite Spoke Wheel $200.00 † 184RW91 22" Lite Spoke Wheel $200.00 † 184RW92 24" Lite Spoke Wheel NC † 184RW93 25" Lite Spoke Wheel NC † 184RW94 26" Lite Spoke Wheel $80.00 † 184RW77 22" Ultra Lightweight Spoke Wheel Only available w/ silver anodized handrim 24" Ultra Lightweight Spoke Wheel $250.00 † 184RW78 † 184RW28 22" Spinergy SPOX Black $695.00 † 184RW95 24" Spinergy SPOX Black $695.00 † 184RW96 25" Spinergy SPOX Black $695.00 Only available w/ silver anodized handrim Wheel/Tire 13.0 13.5 14.0 14.5 15.0 15.5 16.0 16.5 17.0 17.5 18.0 18.5 19.0 19.5 $250.00 X X Wheel NA NA NA NA NA NA NA NA NA NA Ultra Lightweight NA NA NA Mag Lite Spoke Pneumatic 20,22,24 20,22,24,26 24,26 Pneumatic w/Airless Insert 20,22,24 20,22,24,26 24,26 Full Poly Tire 20,22,24 Tire 20,22,24 High Pressure Clincher 22,24,25,26 Knobby V-TRAK Schwalbe Marathon Spinergy 22,24 22,24,25,26 22,24 24,25,26 24 24 24,25,26 Kik Mako Black 24 24,25 24,25 22" = 489 mm 24" = 540 mm Handrim † 184RW97 26" Spinergy SPOX Black $695.00 † 184RW32 22" Spinergy LX Black $895.00 † 184RW98 24" Spinergy LX Black $895.00 † 184HR1 Aluminum Anodized † 184RW99 25" Spinergy LX Black $895.00 † 184HR4 Plastic Coated -NA on every rim † 184RW40 26" Spinergy LX Black $895.00 † 184HR22 Natural Fit - Standard Grip $375.00 † 184RW50 24" Mountain $250.00 † 184HR23 Natural Fit - Super Grip $410.00 184RW25 Omit Rear Wheel and Axle (Intended Size for Set Up ______ ) † 184HR30 Natural Fit LT- Standard Grip $375.00 † 184HR31 Natural Fit LT- Super Grip $410.00 † 184HR24 Spinergy Flex Rim Available on 24" & 25" Spinergy LX wheel $525.00 † 184HR8 NA w/ plastic coated handrims. Only available with 24" or 26 " Mag or Lite Spoke rims. † 184HR7 Omit Handrim NA on every rim † 184AX1 Quick Release Steel 184AX11 Quad Quick Release Mag and Mountain Wheel only † -$55.00 Rear Wheel Tire † 184RT1 E2211 Pneumatic E2212 † 184RT2 E2211 Pneumatic Airless Insert E2213 † 184RT3 E2218 Full Poly † 184RT6 E2211 High-Pressure Clincher E2212 184RT27 E2211 Knobby V-TRAK E2212 † 184RT21 E2211 Schwalbe Marathon Plus Evolution E2212 † 184RT22 E2218 Kik® Mako Black $95.00 † 184RT12 E2211 Mountain Tire Only available E2212 on 24" Mountain Rear Wheel $95.00 † NC Natural Fits available in 22", 24", and 25". Ultra lightweight wheels available w/ alum ano handrim. Not all handrims available on all wheels 8 Oblique $80.00 NC $95.00 $95.00 $240.00 NC Axle † $125.00 NC $95.00 Customer Service: 800-333-4000 Fax: 800-300-7502 Email: [email protected] www.sunrisemedical.com Specifications are subject to change without notice. Copyright © 2012 Sunrise Medical (US) LLC. (11.05) Quickie 2 Lite 108610 REV. L Page 4 NC $90.00 5. BACKREST Back Type Backrest † 184BT10 Standard (9"-20") † 184BT84 Angle Adjustable Back (3" & 4") NC $185.00 Angle Adjustable Back Setting † † 184AH1 † +4° † +5° Push Handles 184PH6 † 184PH11 NC Integral Push Handles Integral Push Handles w/8°Medium & Medium NC † 184B9 Tall NC † 184UX4 9" NC † 184UX14 14" NC † 184UX6 10" NC † 184UX16 15" NC † 184UX8 11" NC † 184UX18 16" NC † 184UX10 12" NC † 184UX20 17"-21" NC † 184UX12 13" NC Back Height Setting $25.00 Tall only, NA w/ Angle Adj Back Fold-Down Push Handles Only available w/ Adj Upholstery † 184PH5 † 184PH2 Omit Push Handles NC 184PH12 Omit Push Handles w/8° Medium & Tall only, NA w/ Angle Adj Back NC † NC 184B5 NC † 0° Select desired setting † Low † NC 3" Pivot Point Setting 184AH2 4" Pivot Point Setting † -14° † -12° † -9° † -7° † -1° See Matrix † 184B1 Backrest Height Matrix $100.00 Back Type NC Standard Upholstery 184BU1 Fixed Backrest Upholstery † † 184BU8 Tension Adjustable Upholstery $175.00 † 184BU14 Omit Back Upholstery -$15.00 Push Handles Backrest Height Low 9"-12" Integral Medium 13"-16" Tall 17"-20" Fold Dow n Om it JAY Back (Optional) 184JB01 Price List J3 Back (See J3 Order Form) Angle Adjustable (3" Pivot) † Military Service Patches (Optional) Only available on tension adjustable upholstery and J3 Back † 184VU1 Marines Patch 184VU2 Army Patch $90.00 † 184VU3 Navy Patch $90.00 † 184VU4 Air Force Patch $90.00 † 184VU12 Coast Guard Patch $90.00 † 184VU5 Purple Heart Patch $90.00 † 184VU8 Purple Heart with Marines Patch $145.00 † 184VU9 Purple Heart with Army Patch $145.00 † 184VU10 Purple Heart with Navy Patch $145.00 Purple Heart with Air Force Patch $145.00 Purple Heart with Coast Guard Patch $145.00 † † 184VU11 184VU13 Angle Adjustable (4" Pivot) $90.00 † 17" max height for shipping Integral Fold Dow n Om it Integral Available Height Range Medium 12"-15" Tall 16"-19" Low 9"-12" Medium 13"-16" Tall 17"-20" Low 13"-16" Medium 17"-20" Tall N/A Medium 16"-19" Low 13"-16" Medium 17"-20" Tall N/A Low 14"-17" Medium 18"-21" Tall N/A Fold Dow n Medium 17"-20" Low 14"-17" Om it Medium 18"-21" Tall N/A 6. ARMREST Padded Swing Away Omit Armrest † Some limitations when used w/ angle adj back in the rear most setting † 184AA18 E0973 Padded Swing-Away STD (9" to 13") † 10" † 11" † 12" Setting † 9" 184AA14 Omit Armrest NC $195.00 † Armpad for Height Adjustable 13" Suggest using classic for tray tables. Contour only available w/ single post height adjustable Height Adjustable † 184AA11 E0973 Single Post Hgt. Adj. Std (8.5"-13.5") $265.00 † 184AM23 Desk Length - Classic (10") NC † 184AA29 E0973 Single Post Hgt. Adj. Low (7"-11") $265.00 † 184AM21 Desk Length - Contour (10") NC † 184AA65 E0973 Flip Back Height Adj LITE (8.5"-13.5") $275.00 † 184AM24 Full Length - Classic (14") NC † 184AM22 Full Length - Contour (14") NC Customer Service: 800-333-4000 Fax: 800-300-7502 Email: [email protected] www.sunrisemedical.com Specifications are subject to change without notice. Copyright © 2012 Sunrise Medical (US) LLC. (11.05) Quickie 2 Lite 108610 REV. L Page 5 7. KEY OPTIONS & ACCESSORIES Wheel Lock Backpack No Gos may exist depending on wheel size and position † High Mount Push 184WL1 NC † 184WL2 † 184WL27 Ergo Scissor $110.00 † 184WL30 Compact $125.00 † 184WL10 Omit NC † 184WL12 Do Not Mount NC Extension Handle Only available w/ high mount push or pull to lock wheel locks on pneumatic or pneumatic w/ airless tire options $55.00 † 184A2 Quickie Kids Backpack Black $50.00 † 184A8 Quickie Seat Pouch Black † 184A500 Gel Cover Hanger/Frame $105.00 † 184A994 Gel Cover Swing Away Arm $105.00 † 184A82 Caddy † 184IG2 Impact Guard Neoprene † 184A54 † 184A83 Seat Pouch $45.00 Additional Cover & Pack Accessories Miscellaneous K0038 Extra Leg Strap Black Tool Kit $45.00 $85.00 $30.00 $45.00 $150.00 E0974 Grade Aid 184GA1 Quickie Backpack Black $65.00 Grade Aid † 184A1 NC High Mount Pull Only available w/ high mount push or pull to lock wheel locks † 184EH7 E0961 Extension Handle (Pair) † Standard Frame Colors † 184C140 † 184C2 † Aztec Gold NC Black (Not avail as base w/Zebra) NC 184C141 Black Cherry NC † 184C10 Black Opal NC † 184C38 Blue Opal NC † 184C36 Candy Blue NC † 184C14 Candy Purple NC † 184C35 Candy Red NC † 184C142 Electric Blue NC † 184C143 Evergreen NC To order any JAY cushions on-chair, please see the JAY price list. † 184C126 Glow NC Cushion name or part number must be filled out with desired width and depth JAY Bundled Cushion † 184C144 Green Applie NC † 184C147 Hot Sparkle Pink NC † 184C148 Mauve Pink NC † 184C103 Rootbeer NC Anti-Tip † 184AT1 $135.00 E0971 Rear Anti-Tip Seat Sling † 184SL6 Omit Seat Sling -$15.00 Cushion † 184CU1 $95.00 E2601 2" Cushion JAY Cushions (Optional) † Cushion Name or Part # 184JC20 Width: Price List Depth: Transit Option NA w/ padded swing away arms † 184TO30 Transit System † 184C114 Sparkle Silver NC † 184C145 Sunrise Orange NC Titanium Color Paint NC Yellow NC † 184C113 $350.00 † 184C8 Side Guard Matte Frame Colors † 184SG33 K0108 Plastic Standard (8.5" High) $125.00 † 184C116 Matte Black † 184SG29 K0108 Plastic Low (6.5" High) $125.00 † 184C151 Matte Black Cherry NC † 184C150 Matte Electric Blue NC † 184C149 Matte Evergreen NC † 184C152 Matte Purple NC † 184C112 Desert Camouflage $295.00 † 184C43 Mossy Oak Camouflage $295.00 † 184C42 Stars & Stripes $295.00 † 184C108 Zebra (Choose above base color) Std with White unless above base paint is chosen NA w/ Black $295.00 Positioning Belts † 184A141 E0978 Belt 1.5" Auto Buckle w/Clamps $70.00 † 184A117 E0978 Belt 2" Aircraft Buckle w/Clamps $110.00 † 184A118 E0978 Belt 2" Aircraft Buckle Pad w/Clamp $120.00 † 184A120 K0108 Positioning Belt Slide Clamps $50.00 Spoke Guards Custom Frame Color Only available w/ Mag, Mountain, and Lite Spoke wheels † 184A23 K0065 Black Spoke Guards $115.00 † 184A302 K0065 Quickie Clear Spoke Guards $115.00 NC Customer Service: 800-333-4000 Fax: 800-300-7502 Email: [email protected] www.sunrisemedical.com Specifications are subject to change without notice. Copyright © 2012 Sunrise Medical (US) LLC. (11.05) Quickie 2 Lite 108610 REV. L Page 6