Zippie Voyage July 2015

Transcription

1 Zippie Vyage July 2015 EIZ14 Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Cnfirm Via: Fax ZIP: Qute Order SHIPPING INFMATION PO#: Ship T: Attentin: Address: Address: Ship T City: ST: Ship T Phne: ( ) Fax: ( ) Cnfirmatin ZIP: Mark Fr: DOB (Date f Birth): mn/dd/yr / / Designed in cnjunctin with Baby Jgger allwing their patented quick fld technlgy which allws ne t fld a base unit after remving the seat in ne simple step and with a secure fld latch fr easy strage. Each unit includes: shand perated Wheel Lck s12" rear tires & lt. weight frnt wheels sfrnt caster suspensin & swivel lcks a 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 Definitin squick release Frnt and rear wheels stelescping strller handle sadjustable seating Shell scanpy w/ breathable windw/mesh pckets a Optin # HCPCS s45 Tilt sfwd & Rwd facing seating capability sunder carriage strage (may be limited when sme ptins chsen) Definitin 198BS7 E BS8 E1234 Vyage with Tllt Includes Slid Seat and Back Vyage with Tilt Seat and Back nt included Vyage (Weight Capacity 60#) 1. FRAME STYLE $2, KJ10 $2, Transit WC-19 Transit Optin (includes H Harness) $ SIZE/SEATING Chse sectin A (when rdering base with seat/back) r B. (when rdering base withut seat/back) Sectin A. (seat ptins when base with seat/back is rdered) Cushin includes: ADJUSTABLE CONTOUR SEAT includes: Planar Seat 198ST65 E2294 Adjustable Cntur Seat $ CU28 E2292 w/ Hip Blcks 198CU41 198CU42 198CU43 Chse Fam E2292 Planar Seat w/ Hip Blck (Pr) 198FM1 E2294 Cntured Wedge Seat 198FM2 Cntured Anti Thrust 198FM3 E2294 (Ledge) Seat Sft Fam Medium/Sft Fam Medium Fam Chse Depth (Based n 1" T Back) Chse Depth (Based n 1" T Back) 198SD78 Shrt 5" - 8" Depth 198SD78 Shrt 5" - 8" 198SD79 Medium 7" thrugh 10" Depth 198SD79 Medium 7" thrugh 10" 198SD80 Lng 9" thrugh 13" Depth 198SD80 Lng 9" thrugh 13" (4" grwth) Custmer Service: Fax: Specificatins are subject t change withut ntice. Cpyright 2014 Sunrise Medical MK REV. A Page 1

2 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 Definitin a Optin # HCPCS Definitin 2. SIZE/SEATING CONT. Chse sectin A (when rdering base with seat/back) r B. (when rdering base withut seat/back) Sectin B. (seat ptins when base rdered withut standard seat/back) Cushin includes: ADJUSTABLE CONTOUR SEAT includes: Planar Seat 198ST60 E2294 Adjustable Cntur Seat 198CU39 E2292 w/ Hip Blcks E2292 Chse Fam 198CU44 Planar Seat w/ Hip Blcks(Pr) $ $ CU37 E CU38 E2294 Cntured Wedge Seat Cntured Anti Thrust (Ledge) Seat $ $ FM1 198FM2 198FM3 Sft Fam Medium/Sft Fam Medium Fam Chse Depth (Based n 1" T Back) Chse Depth (Based n 1" T Back) 198SD78 Shrt 5" - 8" Depth 198SD78 Shrt 5" - 8" 198SD79 Medium 7" thrugh 10" Depth 198SD79 Medium 7" thrugh 10" 198SD80 Lng 9" thrugh 13" Depth 198SD80 Lng 9" thrugh 13" LOWER BODY SUPPTS * d as each, selecting these ptins indicates Qty 2. Hardware Bracket must be chsen with Medial Supprt. Lateral Hip Supprt (Adjusts frm 7.5" t 11" width) Medial Supprt Only available with Planar seat withut Hip Blcks and Adj. Cntur seat. 198KH12 E0957 SM (3"H x 2.5"W x 4.5"L) $ KC4/6 SM (4" x 4", 3/8" thick)* 198KH13 E0957 LG ( 3 3/4"H x 4"W x 6"L) $ KC3/5 LG (5.38" x 4 3/4", 1/2" thick)* 198HE77 E1028 Hardware Medial Supprt Brkt Lateral Thigh Supprt (Adjusts frm 3.5" t 11" width) Only available with Planar seat withut Hip Blcks and Adj. Cntur seat. 198KF4/6 198KF3/5 SM (4" x 4", 3/8" thick)* LG (5.38" x 4 3/4", 1/2" thick)* 3. WHEELS AND CASTERS Standard with Quick release rear and frnt wheels, and frnt wheel suspensin with caster swivel lcks 198WQ07 12" Pnuematic w/ Airless Inserts with 7" casters STD 198F312 K FOOTREST Angle Adj. Ftrest (Required) $ Ftrest adjustment range 1.5" - 12", Shrt Range, the ftplate will be inverted. Chse desired setting, if nt chsen Lng range is default. 198F313 K0037 Preset in shrt range 1.5"-4" 198F314 Preset in lng range 4.5" - 12" Custmer Service: Fax: Specificatins are subject t change withut ntice. Cpyright 2014 Sunrise Medical MK REV. A Page 2

3 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 Definitin a Optin # HCPCS Definitin 5. BACKREST BACKREST OPTION BACKREST SHELL 198KJ9 E1014 Recline Feature ( range) $ BT111 Shrt 7" t 13" Height Desired Backrest Height Setting (Bld indicates default, when nt picked ) 7" 8" 9" 10" 11" 12" 13" 198BT112 Tall 10" t 17" Height Desired Backrest Height Setting (Bld indicates default, when nt picked ) 10" 11" 12" 13" 14" 15" 16" 17" BACK/SEATING OPTIONS Chse sectin A (when rdering base with seat/back) r B. (when rdering base withut seat/back) Sectin A. (Backrest ptins when base with seat/back is rdered) " T " Back 1" Thick " T " Back 2.5" Thick 198BT35 198BT28 E2291 E2291 Shrt 8" t 10" Medium 10" t 12" 2.5" "T" Back is used fr seat depths as small as 3.5", backrest has remvable fam fr additinal depth grwth withut adjusting seat pan. 198BT29 E2291 Tall 12" t 14" 198BT115 E2291 Shrt 8" t 10" Extra Tall 14" t 16" (n/a w Shrt 198BT116 E2291 Medium 10" t 12" 198BT56 E2291 Backrest Shell) 198BT117 E2291 Tall 12" t 14" 198BT BT BT BT106 Extra Tall 14" t 16" (n/a w Shrt 198BT118 E2291 Backrest Shell) Sectin B. (Backrest ptins when base rdered withut standard seat/back) " T " Back 1" Thick " T " Back 2.5" Thick E2291 Shrt 8" t 10" $ " "T" Back is used fr seat depths as small as 3.5", backrest has remvable fam fr E2291 Medium 10" t 12" $ additinal depth grwth withut adjusting seat pan. E2291 Tall 12" t 14" $ BT107 E2291 Shrt 8" t 10" Extra Tall 14" t 16" (n/a w Shrt 198BT108 E2291 Medium 10" t 12" E2291 $ Backrest Shell) 198BT109 E2291 Tall 12" t 14" 198BT110 E2291 Extra Tall 14" t 16" (n/a w Shrt Backrest Shell) POSITIONING AND TRUNK SUPPTS Fr the supprts, Vyage will be set up at factry, insert dimensins n last page spec drawing. Nt required, will default t std. settings Lateral Trunk Supprt (Adjustment listed belw) Laterals Height Adjustment Range based n Backrest shell height chsen in Sec. 5. i.e. Shrt Height Lats adj. 3" - 12", Tall Height Lats Adj. 3" - 17" *d as each, selecting these ptins indicates Qty KE25/24 198KD15/19 198KD13/17 198KE42/41 198KD15/19 198KD16/20 198KD13/17 198KD14/18 E1028 Fixed Angle Adjustable* Large Straight Pad 3" x 6"* Small Straight Pad 2" x 6"* *Fixed adj. 1"-10" widths Swing Away* Large Straight Pad 3" x 6" Large Curved Pad 3" x 6" Small Straight Pad 2" x 6" Small Curved Pad 2" x 6" *S/A Std. adj. 1"-8" widths Cmfrt Fit ATS Anterir Trunk Supprt (Lil Kidds) 198A820 E0960 Cm Fit ATS9107 xxs 9.5 pad 198A821 E0960 Cm Fit ATS9100 xs 12.5" pad 198A822 E0960 Cm Fit ATS9101 sm 15"pad Anterir Trunk Butterfly Supprt Dimensins are seat t shulder height. 198KI1 198KI2 198KI3 198KI4 198KI5 Only available with Butterfly Supprt 198SS1 E0960 E0960 XX Small Butterfly Pad (< 10") X Small Butterfly Pad (10" - 12") E0960 Small Butterfly Pad (12" - 14") E0960 Medium Butterfly Pad (14" - 16") E0960 Large Butterfly Pad (>16") E0960 Trunk Supprt Optins Shulder Strap Pads $ $ $ $25.00 Anterir Trunk H Strap Supprt (included with Transit) 198SS2 E0960 XX Small H Strap 5 Pint $ Custmer Service: Fax: Specificatins are subject t change withut ntice. Cpyright 2014 Sunrise Medical MK REV. A Page 3

4 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 Definitin a Optin # HCPCS Definitin 6. KEY OPTIONS HEAD Supprt Optins Hardware allws the headrest t be flushmunted t backrest when abve shell. When chsing a Headrest ptin, Hardware Bracket must be chsen, Hardware avail individually as well. Headrest Ht. Adj, Range based n Backrest shell hgt chsen in Sec. 5. i.e. Shrt Height adj.9" " & Tall Height Adj.13" -23.5" frm seat pan. 198HE40 E0955 Whitmyer 8" Plush 198HE41 E0955 Whitmyer 10" Plush 198HE42 E0955 Whitmyer SM Cntur Cradle 198HE43 E0955 Whitmyer Med Cntur Cradle 198HE29 E0955 Whitmyer Sm Adjust-a-Plush $ Whitmyer DFS(Frehead Strap) $ HQ6 K0108 Squared fr Single pad, must rder Whitmyer headrest She Hlders E0952 6" Lng She Hlders $ A68 E0951 E0952 8" Lng She Hlders $ A69 E HE31 198A79 198A80 198A91 198A92 E1028 E0952 E0952 E0950 E0950 Hardware Bracket Only (can be chsen w/ headrest) Ft Straps 16" Ft Straps with Cvers 18" Ft straps with Cvers $ $35.00 $35.00 Upper Extremity Supprt Tray (Angle Adjustable Hardware Included) Tray Munt adjusts frm 4.5"-7.5" with 1" tall cushin Light Grey Clear Ply $ $ Misc Accessries 198LF5 Cup Hlder/ Bttle/Feeding $ LF7 Utility Hk (i.e.suctin canister) $ A462 Rain Cape $ Pelvic Psitining Belt Must use when rdering Anterir Trunk Supprts. 198A14 198A15 198A A A A LF1 198LF11 198LF2 198LF3 198LF4 198A74 198A A A78 1" Padded 1.5" Padded 1" Padded Aut Style 1.5" Padded Aut Style Cmfrt Fit APB5145 XS Pad Cmfrt Fit APB5146 Sm Pad Accessries Dvetail Vertical Frame Munted Hardware fr LTV ventilatrs (limit 15#) includes 1 Utility hk Dvetail Vertical Frame Munted Hardware fr Trilgy ventilatrs (limit 15#) includes 1 Utility hk Battery and Vent/Utility Underframe Tray (limit 50#, ideal fr U1 r Grp 22 Batteries) includes 1 Utility hk Frnt Munt Utility platfrm (limit 50#) Rear Add n Accessry platfrm (limit 45# r ne Grp 24 battery) includes 1 Utility hk. Must be remved r flded befre flding base K0105 IV Supprt Ple E2208 O2 Tank Hlder K0105 E2208 E1399 IV/O2 Cmbinatin Flr Sitter/ Feeder Base Flding Bster Base (Ht. Adj.) $45.00 $45.00 $55.00 $55.00 $95.00 $95.00 $ $ $ $ $ $ $ $ $ IV Supprt Ple Cup Hlder Frnt Munt Utility Platfrm Utility Hk Upper Extremity Supprt Tray Flding Bster Base O2 Tank Hlder Battery and Vent/Utility Underframe Tray Dvetail Vertical Vent Munt (LTV/Trillgy) Rear Add On Accessry Platfrm Custmer Service: Fax: Specificatins are subject t change withut ntice. Cpyright 2014 Sunrise Medical MK REV. A Page 4

5 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 Definitin a Optin # HCPCS Definitin 7. COLS Clr Optins - Slid Custm Optin (Only available with Prints) Slid Clrs Custm Clr Selectin: Chse & 198CL9 Purple 198C001 Enter frm Slid Clr Optins: 198CL20 Pink Srbet 198CL11 198CL12 Green Navy Blue Canpy Pattern 198CL13 Orange 198UF01 Crss Over 198CL17 Turquise 198UF02 Center Stripe 198CL16 198CL18 Black Burgundy Clr Optins - Print (Std. Trim listed behind each print) 198CL19 Lepard (Std w/ Black Trim) 198CL14 Butterflies (Std w/purple Trim) 198CL15 Red Race Flags (Std w/ Red Trim) Crss Over Center Stripe Custmer Service: Fax: Specificatins are subject t change withut ntice. Cpyright 2014 Sunrise Medical MK REV. A Page 5

6 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 Definitin a Optin # HCPCS Definitin Desired Set Up Specificatins (Nt Required) Child's Name Age: Diagnsis: Height: Weight: 1. Tp f Head t Seat: Tp f Shulder t Seat*: Under Arm t Seat: 9. Width f Head: Shulder Width: Chest Width: 4. Trunk Depth: 10. Hip Width: 5. Actual Sitting Depth*: 11. Left Lwer Leg Length*: 6. Ft Length: 12. Right Lwer Leg Length*: * Critical Dimensins Custmer Service: Fax: Specificatins are subject t change withut ntice. Cpyright 2014 Sunrise Medical MK REV. A Page 6