Quickie GP Swing-Away Order Form (July 2014)

Quickie GP Swing-Away Order Form (July 2014)
Quickie GP Swing Away
July 2014
SUBMIT
EIGPSA
Mark For:
Submitting for:
Date:
PO#:
o Quote
o Order
Dealer Acct #:
Dealer:
ADDITIONAL SHIPPING INFORMATION
Dealer Contact:
Ship To:
Dealer Address:
Attention:
Dealer City:
Dealer Phone: (
Confirmation Email:
Confirm Via:
ST:
)
Address:
ZIP:
Fax: (
Address:
)
Ship To City:
o Fax
o 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.
a
Option #
HCPCS
Definition
Price
a
Option #
HCPCS
Definition
Price
1. FRAME STYLE
o
025WM26
K0005 Quickie GP Swing-Away
$2,095.00
2. FRAME STYLE & SET UP
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
025C140
025C2
025C141
025C10
025C38
025C36
025C14
025C35
025C142
025C143
025C126
025C144
025C147
025C148
025C103
025C114
025C145
025C113
025C8
o
o
o
o
o
025C116
025C151
025C150
025C149
025C152
o
o
o
o
025C112
025C43
025C42
025C108
Standard Frame Colors
Aztec Gold
Black (Not avail as base w/Zebra)
Black Cherry
Black Opal
Blue Opal
Candy Blue
Candy Purple
Candy Red
Electric Blue
Evergreen
Glow
Green Apple
Hot Sparkle Pink
Mauve Pink
Rootbeer
Sparkle Silver
Sunrise Orange
Titanium Color Paint
Yellow
Matte Frame Colors
Matte Black
Matte Black Cherry
Matte Electric Blue
Matte Evergreen
Matte Purple
Custom Frame Color
Desert Camouflage
Mossy Oak Camouflage
Stars & Stripes
Zebra
Frame Width
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
Seat Width 1/2" Narrower
o
025W3
o
025W4
o
025W5
o
025W6
o
025W7
o
025W8
o
025W9
12"
13"
14"
15"
16"
17"
18"
NA w/ adj. upholstery
NA w/ adj. upholstery
o
o
025W41
025W11
Frame Width - Continued
19"
E2201 20"
o
o
o
o
o
o
o
o
o
o
o
025SD5
025SD6
025SD7
025SD8
025SD9
025SD10
025SD11
025SD74
025SD13
025SD14
025SD33
12"
13"
14"
15"
16"
17"
18"
19"
E2203 20"
E2203 21"
E2204 22"
NC
NC
NC
NC
NC
NC
NC
$125.00
$500.00
Sling Depth
NC
NC
NC
NC
NC
NC
NC
$125.00
$550.00
$550.00
$900.00
$295.00
$295.00
$295.00
$295.00
3. SEATING
o
o
o
025CU1
025CU2
025CU4
Cushion
K0669 2" Cushion
Omit Cushion
Omit Cushion and Seat Sling
$120.00
NC
-$15.00
JAY Bundled Cushions - Optional
To order any JAY cushions on-chair, please see JAY Price List. Cushion name
or part number must be filled out with desired width & depth.
JAY Bundled Cushion
o
025JC20 Cushion Name or Part #:
Price List
Width:
Depth:
Customer Service: 800-333-4000 Fax: 800-300-7502 Email: orders@sunmed.com www.sunrisemedical.com
Specifications are subject to change without notice. Copyright © 2012 Sunrise Medical (US) LLC. Quickie GP SA MK-100023 REV B
Page 1
4. BACKREST
o
o
025BT1
o 025BA1
o 025BA2
o 025BA3
o 025BA4
025BT3
o
o
o
o
o
o
o
o
o
Back Type
Folding Backrest (Adjustable)
11" - 14" Back Height
12" - 16" Back Height
14" - 18" Back Height
16" - 20" Back Height
Non-Folding Backrest (Fixed)
$65.00
$65.00
$65.00
$65.00
NA with push handles or adj. upholstery
025BB1
025BB2
025BB3
025BB4
025BB5
025BB6
025BB7
025BB8
025BB9
8" Back Height
9" Back Height
10" Back Height
11" Back Height
12" Back Height
13" Back Height
14" Back Height
15" Back Height
16" Back Height
NC
NC
NC
NC
NC
NC
NC
NC
NC
o
o
o
o
025BU1
025BU8
025BU16
025BU14
o
025BT33
o
025A85
o
025SR2
o
025SR3
o
025JB01
Back Upholstery
Standard
Adjustable
Reinforced (NA w/ adj. upholstery)
Omit Back Upholstery
Backrest Options
Folding w/ Integral Push Handles
Bolt-On Push Handle (Folding only)
NA with Xtender Power Assist
NC
$175.00
$30.00
-$15.00
NC
$115.00
Regular Stroller Handle
NA with amputee axle plate or Xtender
Power Assist
$125.00
Tall Stroller Handle
NA with amputee axle plate or Xtender
Power Assist
JAY Back (Optional)
J3 Back (See J3 Order Form)
$125.00
Price List
5. FOOTREST
o
o
Hangers
60° Swing Away
70° Swing Away
025H1
025H2
NC
NC
90° Swing Away
o
025H6
o
025H14
E0990
o
025H24
K0053
Only available with kids angle adjustable,
adult angle adj. NA with extension tubes
Elevating Hanger
Only available w/
alum or angle adj footplates.
Articulating
Only available w/ alum or
angle adj footplates.
Footplates
Heel loop or leg strap not included, See Footplate Options Section
Composite Footplate 14"-20"
o
025F1
NA w/ 90° hangers and ELRs
o
025F3
K0040 Adult Angle Adjustable
Kids Angle Adjustable
o
025F4
K0040
Only available on 12"-16" width
Platform Flip Up
o
025F48
K0040
Available w/ 60° and 70° hangers
o
025F5
o
025F7
Aluminum
Only available w/ ELRs
Omit Footplate & Ext Tube
NC
$295.00
$350.00
Footrest Extension Tubes
See Chart on the bottom of the page for lengths
o
025E1
Short NA w/ ELR or ALR
o
025E2
Medium
o
025E5
Long
o
025E16
o
o
025E12
025E15
o
o
o
025HL1
025HL5
025HL4
o
025IG2
NC
$185.00
$185.00
$190.00
K0037
High Mount Only avail. with adult
and kids angle adjustable footplates
Short ELR
Long ELR
Footrest Options
E0951 Heel Loop
K0038 Leg Strap
Omit Heel Loop
Impact Guard Neoprene (Only avail.
On 60° or 70° hangers)
NC
NC
NC
$55.00
NC
NC
$30.00
$35.00
NC
$85.00
NC
-$15.00
6. CASTERS
o
o
o
o
025CW1
025CW3
025CW31
025CW5
o
025CW7
o
025CW6
o
025CW33
o
025CW34
o
025CW35
o
025CW21
o
025CW32
Caster Wheels
3" Micro
4" Low Profile Polyurethane
4" Micro Lighted
5" Low Profile Polyurethane
5" x 1.5" Semi-Pneumatic only avail.
for use in bottom fork holes
5" Soft Roll Semi-Pnuematic
E2214
6" Pneumatic
E2215
6" Polyurethane
6" x 1.5" Semi-Pneumatic only avail.
for use in bottom fork holes
E2214
8" Pneumatic
E2215
8" Polyurethane
NC
NC
$70.00
NC
o
025CW36
o
025CW37
$85.00
$85.00
o
025CS5
o
025CS9
$75.00
NC
Caster Wheels - Continued
E2214
8" x 2" Pneumatic
E2215
E2214
8" x 2" Pneumatic w/Airless Insert
K0108
Caster Fork Options
3/4" Longer Fork Stem Bolt N/A w/
Xtender Power Assist Option
1-1/2" Longer Fork Stem Bolt N/A w/
Xtender Power Assist Option
$85.00
$75.00
NC
Customer Service: 800-333-4000 Fax: 800-300-7502 Email: orders@sunmed.com www.sunrisemedical.com
Specifications are subject to change without notice. Copyright © 2012 Sunrise Medical (US) LLC. Quickie GP SA MK-100023 REV B
Page 2
$145.00
$225.00
NC
NC
7. ARMREST
Single Post
Single Post Ht. Adjust. Low
o
025AA9
E0973
o
o
025AM1
025AM2
o
025AA8
E0973 Desk Length - Classic (10")
E0973 Full Length - Classic (14")
Single Post Ht. Adjust. Std
E0973
o
o
025AM1
025AM2
E0973 Desk Length - Classic (10")
E0973 Full Length - Classic (14")
Must be removed to fold back down
Must be removed to fold back down
Padded Swing Away Armrest
$285.00
NC
NC
All Padded Swing-Away NA with amputee axle plate or Xtender Power Assist
o
o
025AA19
025AA16
$210.00
$210.00
E0973 Padded S-A Medium
E0973 Padded S-A Adult
$285.00
NC
NC
8. AXLE & WHEEL OPTIONS
Axle Plate
N/A w/ Power Assist
o
025AL2
o
025AL6
Standard Adjustable
E0959
Amputee Adjustable NA with padded
swing-away armrests or stroller handles
025AL13
Double Slotted Adjustable
o
o
025AX1
025AX11
Axle
Quick Release Steel
Quad Quick Release
o
025AT1
o
o
025RW8
o
025RW9
o
o
025RW1
025RW2
o
025RW11
Rear Anti-Tip
E0971 Rear Anti-Tip
Rear Wheel Type
22" Mag
NA with Xtender or 8" x 2" casters
22" Spoke
NA with Xtender or 8" x 2" casters
24" Mag
24" Spoke
26" Spoke
NA with Xtender or 8" x 2" casters
NC
Projection Hand Rim
NA with plastic coated hand rims.
o
025HR8
8 Oblique
$175.00
025WL1
025WL2
o
025WL5
NC
$125.00
o
o
025WL12
025WL10
Do Not Mount
Omit
$140.00
o
025EH1
Extension Handle
E0961 6" Pair
NC
o
025RT1
o
025RT2
o
025RT3
o
025RT6
E2211
Pneumatic
E2212
E2211 Pneumatic Airless Insert
E2213 NA with 26" wheels
Full Poly
E2218
NA with 26" wheels
E2211 High-Pressure Clincher Only avail. On
E2212 24" or 26" spoke rims
025GA1
or extension handles
$125.00
NC
NC
$75.00
Grade Aid
Grade Aid NA w/ poly, high-pressure
E0974
NC
NC
clincher tires
$150.00
$200.00
NC
NC
Seat Sling to Top of Footplate Range
60° Swing- Away
$65.00
60° Swing- Away
Rear Wheel Tire
o
Wheel Lock
High Mount Push
High Mount Pull
High Mount Scissor NA w/ grade aids
o
o
$60.00
$325.00
NC
12 - 153/4
Short Ext.
Medium Ext. 141/2 - 181/4
60° Swing- Away
Long Ext.
17 - 203/4
60° Platform Flip-Up
Short Ext.
123/8- 155/8
60° Platform Flip-Up Medium Ext. 141/2 - 173/4
$80.00
NC
60° Platform Flip-Up
Long Ext.
17 - 201/4
70° Swing- Away
Short Ext.
11 - 143/4
70° Swing- Away
$95.00
Medium Ext. 131/2 - 171/4
70° Swing- Away
Long Ext.
16 - 193/4
70° Platform Flip-Up
Short Ext.
115/8 - 153/8
70° Platform Flip-Up Medium Ext. 133/4 - 171/2
70° Platform Flip-Up
Hand Rim
NA with Xtender Power Assist
o
025HR1
Aluminum Anodized
o
025HR4
Plastic Coated -NA on all rims
o
025HR7
Omit Hand Rim
Long Ext.
161/4 - 20
*All adjustment ranges may vary due to seat height
restrictions. Recommended 21/2" f ootrest clearance
to ground surf ace.
NC
$95.00
NC
9. Xtender Power Assist Options
Xtender Power Assist
Rear seat height of 16.5" only. Higher seat heights available through B4M.
Xtender Power Assist 4X Multiplier
o
025XT2
E0986
$6,595.00
NICKEL
Xtender Power Assist 4X Multiplier
o
025XT3
E0986
LITHIUM
Please select one of the following handrim options
025XH3
Plastic Coated
o
025XH4
Stainless Steel
o
$7,595.00
o
025XW1
o
o
025XA1
025XA7
Xtender - Tire Option
E2211
Pneumatic
E2212
Xtender - Other Options
Spare NiMH Power Pack - NICKEL
Spare NiMH Power Pack - LITHIUM
NC
NC
Customer Service: 800-333-4000 Fax: 800-300-7502 Email: orders@sunmed.com www.sunrisemedical.com
Specifications are subject to change without notice. Copyright © 2012 Sunrise Medical (US) LLC. Quickie GP SA MK-100023 REV B
Page 3
NC
$1,395.00
$1,795.00
10. KEY OPTIONS & ACCESSORIES
o
o
025A1
025A2
Backpack
Quickie Backpack Black
Quickie Kids Backpack Black
$55.00
$50.00
o
025A8
Seat Pouch
Quickie Seat Pouch Black
$45.00
Crutch Holder
Can only mount on left side from rear
o
o
o
025A53
E2207 Left Side Mount
025A55
Extra Leg Strap
K0038 Extra Leg Strap Black
025A83
Miscellaneous
Tool Kit
o
o
o
025A142
025A12
025A13
Positioning Belts
E0978 Belt 1.5" Auto Buckle
E0978 Belt 2" Aircraft Buckle
E0978 Belt 2" Aircraft Buckle Padded
Spoke Guards
NA w/ Xtender Power Assist
o
025A23
K0065 Black Spoke Guards
o
025A24
K0065 Clear Spoke Guards
$70.00
$110.00
$120.00
$115.00
$115.00
$195.00
Tray Table
E0950 Tray Table
$250.00
Side Guard
NA w/ height adjustable arms
o
025SG3
K0108 Plastic Regular
o
025SG4
K0108 Plastic Kids
$125.00
$125.00
o
025A31
$30.00
$45.00
Customer Service: 800-333-4000 Fax: 800-300-7502 Email: orders@sunmed.com www.sunrisemedical.com
Specifications are subject to change without notice. Copyright © 2012 Sunrise Medical (US) LLC. Quickie GP SA MK-100023 REV B
Page 4
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