Zippie X'CAPE July 2016 EIFZ1

Transcription

1 Zippie X'CAPE July 26 EIFZ Date: Dealer Acct #: Dealer: Dealer Cntact: Dealer Address: Dealer City: ST: Dealer Phne: ( ) Fax: ( ) Mark Fr: ZIP: SUBMITTING FOR: Qute Order Address: Address: 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. PO#: Ship T: Attentin: Ship T City: Cnfirm Via: Fax Ship T Phne: ( ) Fax: ( ) ST: ZIP: a Optin # HCPCS Definitin K5 cding still applies fr certain sizes A. Zippie X'CAPE - TRANSIT ILUDED (65lbs) A. FRAME STYLE (Includes True Fit) 2WM87 E238 X'CAPE - Transit Inc withut seating (Custm seating pts available) $2,385. 2WM84 E236 X'CAPE - Transit Inc w/ Seating (Sling and Back Uphl) $2,535. a. FRAME Optin # HCPCS Definitin B. Zippie X'CAPE - TRANSIT OPTIONAL (65lbs) 2WM83 2WM85 B. FRAME STYLE (Includes True Fit) E238 X'CAPE - Transit Opt withut seating (Custm seating pts available) $2,35. E236 X'CAPE - Transit Opt w/seating (Sling and Back Uphl) $2,285. TRANSIT SYSTEM WC-9 2TO48 Transit Opt. $3. 2TO4 Omit Transit FRAME TYPE 2FT64 Zippie-Swing Away Frame 2FT65 Zippie-8 Fixed Frnt Frame 2. SIZE/SEATING 2A. FRAME WIDTH 2W48 8" (Frame Width Grwth 9-") 2W53 3" (Frame Width Grwth 4-5") 2W49 9" (Frame Width Grwth -") 2W54 4" (Frame Width Grwth 5-6") 2W5 " (Frame Width Grwth -2") 2W55 5" (Frame Width Grwth 6-7") 2W5 " (Frame Width Grwth 2-3") 2W56 6" (Frame Width Grwth 7-8") 2W52 2" (Frame Width Grwth3-4") 2B/C. SLING DEPTH, FRAME DEPTH AND BACK POST POSITION. See matrix n page 2. 8"-" Frame Depth with 2",22" r 24" wheels and Custm Seating must have hublck r Fixed Frnt frame. When selecting Frame Depth with custm seating, add " t accmmdate seating. Example: need 2 depth, rder 3 depth. 2B. Sling Depth when chsing with Seating * Sling must be up t 3" less than r equal t the Frame Depth (C.) 2GJ 8" 2GJ7 4" 2GJ2 9" 2GJ8 5" 2GJ3 " 2GJ9 6" 2GJ4 " 2GJ 7" 2GJ5 2" 2GJ 8" 2GJ6 3" 2C. Frame Depth and Back Pst Psitin with Grwth *must be equal r greater than Sling Depth if chsen with seat Sling 8" ( Frame depth grwth 9"-", 2FD46 4" ( Frame depth grwth5"-7") 2FD4 NA w/ 24" wheels) 2FD47 5" ( Frame depth grwth 6"-8") 9" ( Frame depth grwth "-2", 2FD48 6" ( Frame depth grwth 7"-9") 2FD4 NA w/ 24" wheels) 2FD49 7" (Frame depth grwth 8"-2") 2FD42 " ( Frame depth grwth "-3") 2FD5 8" (Frame depth grwth 9"-2") 2FD43 " ( Frame depth grwth 2"-4") 2FD44 2" ( Frame depth grwth 3"-5") 2FD45 3" ( Frame depth grwth 4"-6") Custmer Service: Fax: [email protected] Specificatins are subject t change withut ntice. Cpyright 25 Sunrise Medical (US) LLC. (.5) Zippie X'CAPE MK-2 REV. I Page

2 a Optin # HCPCS Definitin a Optin # HCPCS Definitin SEATING Seat Sling Sling and " Cushin Matrix 2OP 2OP4 Standard Seat Sling Width STD Omit Seat Sling (available when base 8 8 is rdered with seating) 9 9 Cushins Sme limitatins may exist n 2" Cushin and smaller widths 2 2 2CU3 " Fam Cushin $ CU3 2" Fam Cushin $ JAY Cushins (Optinal) 6 6 T rder any ther JAY cushins n-chair, please see the JAY price list. 7 7 Cushin name r part number must be filled ut w/ desired width and depth 8 8 JAY Bundled Cushin JC2 Cushin Name r Part# List Width Width: Depth: " cushin available at these sizes " cushin NOT available at these sizes frame length Seat Sling t Frame Depth Matrix 2" Cushin Matrix Difference frm frnt f frame Width t frnt f sling (inches) sling length Width 2" cushin available at these sizes 2" cushin NOT available at these sizes 3.CASTERS/SEAT HEIGHT Sling Depth Sling Depth Sling Depth Sling Depth Caster Wheel 2CW3 3" Micr Light Up 2CW3 4" Lw Prfile Plyurethane 2CW3 4" Micr Light Up $7. 2CW64 4" x.5" Aluminum Sft Rll $75. 2CW5 5" Lw Prfile Plyurethane 2CW5 5" Micr Light Up $85. 2CW6 5" Sft Rll (Grey) $85. 2CW7 5"x.5" Semi Pneumatic $85. 2CW66 5"x.5" Aluminum Sft Rll $85. 2CW34 6" Ply 2CW35 6"x.5" Semi Pneumatic $85. Caster Frks Carbtecture NA w/ 6" casters. Multiple Psitin nly avail. w/ 6" casters 2CF74 Carbtecture Frk 2CF65 Multiple Psitin Standard Frame Hemi Fame Depends n Caster setting Rear Wheel Size Frnt Seat Heights Matrix Frnt Caster " " " " " FRONT SEAT HEIGHTS ARE SHOWN IN THE BOXES IN THE FRONT SEAT HEIGHTS MATRIX. DEPENDING ON CG SETTING, SEAT DEPTH, AND FRAME SIZE SOME OF THE SIZES MAY NOT BE AVAILABLE Custmer Service: Fax: [email protected] Specificatins are subject t change withut ntice. Cpyright 25 Sunrise Medical (US) LLC. (.5) Zippie X'CAPE MK-2 REV. I Page 2

3 a Optin # HCPCS Definitin a Optin # HCPCS Definitin 4.REAR WHEELS/SEAT HEIGHT Rear Wheels 5 Spke Mag Wheels NA w/ Hub Lck. Std Mag Wheels nly available with One Arm Drive. 24" wheels NA with 8" and 9" frame depths. 8"-2" Frame Depth with 2-24" Rear Wheels and ELR's is ONLY available with Hub Lck Wheels. 2RW48 2RW4 2RW3 2RW8 2RW 2RW3 2RW4 2RW2 2RW74 2RW75 2RW76 2RW6 2RW 2RW28 2RW95 2RW32 2RW98 2RT3 2RT6 2RT27 2RT38 2RT 2RT2 2RT2 2RT28 2RT4 E228 E228 E223 E228 2" Mag (Nt available with handrims r ne arm drive) 6" Mag (Nt available with handrims r ne arm drive) 2" Mag Wheel 22" Mag Wheel 24" Mag Wheel 2" Mag Wheel 5 Spke 22" Mag Wheel 5 Spke 24" Mag Wheel 5 Spke 2" Lite Spke Wheel 22" Lite Spke Wheel 24" Lite Spke Wheel 22" Ultra light wt. Spke Wheel 2. 24" Ultra light wt. Spke Wheel 2. 22" Spinergy SPOX Black Spkes 24" Spinergy SPOX Black Spkes 22" Spinergy LX Black Spkes 24" Spinergy LX Black Spkes Rear Wheel Tire Full Ply Tire High Pressure Clincher Knbby V-TRAK by Kenda SHOX Perfrmance Ply Pneumatic Pneumatic Airless Insert Schwalbe Marathn Plus Evlutin Schwalbe Speed Lw Ply $4. $25. $25. $795. $795. $995. $995. $95. $95. $95. $8. Handrim Natural Fit NA w/ 2" and 22" 5 Spke Mag Wheel 2HR Aluminum Andized Plastic Cated (N/A n Ultra and 22" 2HR4 Spinergy LX,SPOX) 2HR22 2HR23 2HR3 2HR3 2HR24 2HR7 2AL33 2AL6 2OA2 2HM 2HM2 2OA 2HM 2HM2 2AX 2AX E958 Natural Fit -Standard Grip (N/A n Ultra Lite r 2" Lite Spke) Natural Fit - Super Grip (N/A n Ultra Lite r 2" Lite Spke) Natural Fit LT - Standard Grip (N/A n Ultra Lite r 2" Lite Spke) Natural Fit LT - Super Grip (N/A n Ultra Lite r 2" Lite Spke) Spinergy Flex Rim (Only n 24" Spinergy LX) Omit Handrim (Optin may nt be available n all rear wheels) Standard Axle Plate One Arm Drive Standard Handrim Right Hand Munt Left Hand Munt Small Handrim (nt avail w/2" rear wheels) Right Hand Munt Left Hand Munt Axle $95. $375. $4. $375. $4. $525. One Arm Drive NA w/ 2"-6" wheels. Only avail. On 2"-6" widths and 2", 22" and 24" mag wheels.na with Natural Fit handrims.na with SPHA arms. Quick Release (NA w/one Arm Drive) Quad Quick Release (Only Available with 2 and 6 Mag Wheels) $85. Tire Full Ply Tire Schwalbe Marathn Plus Schwalbe Speed Run Wheel Lite Spke 2,22 High Pressure Clincher 22,24 SHOX Perfrmance Ply Knbby V-TRAK Pneumatic Pneumatic Airless Insert Lw Ply 5 Spke Mag Std. Mag 2,6, 2,6, 2 22" = 489 mm 24" = 54 mm 24 Spinergy 22, , ,24 22,24 22, ,24 24 Ultra Lightweight 22,24 22,24, Custmer Service: Fax: [email protected] Specificatins are subject t change withut ntice. Cpyright 25 Sunrise Medical (US) LLC. (.5) Zippie X'CAPE MK-2 REV. I Page 3

4 a Optin # HCPCS Definitin a Optin # HCPCS Definitin 4.REAR WHEELS/SEAT HEIGHT Cnt. Center f Gravity Preset (dependent n wheels, casters & depth, Frm standard frame depth +2" frward and - depth grwth up t -3" ) Rear Wheel 2 lw ply 2CC28 2CC26 2CC6 2CC2 2CC5 2CC7 2CC8 2CI 2CI2 -.5" (Flush w/ backrest) Camber Rear Seat Height pneu pneu When tires are nt listed default t the Wheel size. All Heights are subject t vary slightly.5" Only avail 9"-8" deep " Only avail "-8" deep.5" Only avail "-8" deep º 2" Only avail 6"-8" deep 2.5" Only avail 6"-8" deep 3º (NA w/ Single Pst Ht Adj Arm) Rear Seat Height (see Allwable Squeeze chart) 2RH32 " 2RH33.5" 2RH9 2" 2RH 2.5" 2RH 3" 2RH2 3.5" 2RH3 4" 2RH4 4.5" 2RH5 5" 2RH6 5.5" 2RH7 6" 2RH8 6.5" 2RH9 7" 2RH26 7.5" 2RH2 8" Allwable Squeeze (may vary +/-.5") Frame Depth Max Squeeze 8"-9"." "-2".5" 3"-5" 2." 6"-8" 2.5" 5. WHEEL LOCK Hub Lck Only available with 2" r 6" mag wheels r Lite Spke wheels. Nt available with ne arm drive. 2LK 2LK2 2LK4 2HH 2HH2 2HH3 2" Hub Lck $. 6" Hub Lck $. 2"-24" Hub Lck Lite Spke $. Hub Lck Munt Psitin Ftlck may limit flding width. Ftlck Munt Seat Munt Back Munt (back ht may be limited) High Munt Push High Munt Pull Cmpact Wheel Lck NA with Hub Lck. High Mt will be munted in lw psitin n 2 and 6 rear wheels. Sme may nt be available depending n wheel size and psitin. 2WL 2WL2 2WL3 2WL Omit Swing Away 8"-2" Frame Depth Wheel Lck g/n-g matrix Frame 2" 22" 24" C.G. Depth wheel wheels wheels Extensin Handle (Only avail w/ High Munt Wheel Lcks) 2EH E96 6" Pair $75. N-g. User must use hublck. G Custmer Service: Fax: [email protected] Specificatins are subject t change withut ntice. Cpyright 25 Sunrise Medical (US) LLC. (.5) Zippie X'CAPE MK-2 REV. I Page 4

5 a Optin # HCPCS Definitin a Optin # HCPCS Definitin 6. HANGER AND FOOTREST 2H62 2H6 2H44 Hangers/Ftrest System NA n Fixed Frame. Sme interference may exist in certain cnfiguratins. Z-finity Hanger Elevating Hanger - Ext Munt Includes ELR pad. NA w/ Z-finity. Sme limitatins may exist. Omit Hanger STD $295. 2HL8 2HL 2IG2 K38 E95 Direct Hanger Munt Ftrest Optins Leg Strap $35. Heel Lps NA n widths belw 4" Neprene Impact Guards NA with ftrest in highest munted psitin Extensin Tube Munt $3. $85. Z-finity Ftrest Munt (Must Chse see Illustratin) 2DI22 Direct Hanger Mt/Fixed Frame - High 2DI23 Direct Hanger Mt/Fixed Frame - Lw 2DI24 Extensin Tube Munt Z-finity Ftrest Pivt Arm (Must Chse, use matrix fr leg length) 2DI2 Shrt 2" 2DI2 Lng 3 /4" Shrt Pivt Arm Lng Pivt Arm Sme interference may exist in certain cnfiguratins. 2F32 K4 Multi Angle Adjustable (Pair) (nt avail. w/8"-9" widths) 2F32 2F6 K4 Ftplate Angle Adjustable Platfrm Ftbard Omit Ftplate $85. $5. ExtensinTube Length (When Chsing Ext. Tube Munt) 2E62 K4 Hemi 2E K4 Shrt 2E2 K4 Medium 2E5 K4 Lng Custmer Service: Fax: [email protected] Specificatins are subject t change withut ntice. Cpyright 25 Sunrise Medical (US) LLC. (.5) Zippie X'CAPE MK-2 REV. I Page 5

6 a Optin # HCPCS Definitin a Optin # HCPCS Definitin 7. BACKRESTS BACKREST 2BT Standard Backrest (Angle adj/flding) 2BT Dynamic Backrest (NA w/fixed Back) $,95. BACK TYPE (Chse Height Adjustable r Fixed Height) 2BT2 Height Adjustable (see matrix belw) OR 2BT53 Fixed Height Height Adjustable (See Backrest Height Range matrix) Fixed Height Must chse Lwer Base Tube, Backrest Style, and Upper Back Tube. Fixed Height back NA with uphlstery Lwer Base Tube (See Backrest Height Matrix Belw) 2BP9 Standard (6" Ht) 2BP58 Shrt 2BP Medium (2" Ht) 2BP59 Medium 2BP Tall (23" Ht) 2BP6 Tall (NA with Dynamic Backrest) Backrest Styles (See Images Belw) 2BP6 2BP62 2BP63 Standard w/flding PH (6" Ht) Medium w/flding PH (2" Ht) Tall w/flding PH (23" Ht) $225. $225. $225. 2PH6 Straight Nn Push Handle 2PH6 Integral Push handle 2PH7 Flding Push Handle with Ht. Adj. Back $225. 2PH5 Omit Back Tube (See mit matrix) Upper Back Tube (See Backrest Height Matrix Belw) 2B245 Shrt 2B5 Medium 9" Height Adjustable Backrest Preset Backheight (Chse fr Set Up) N Uphlstery w/ 9'-24" " 5" 2" 6" 2" 2" 7" 22" 3" 8" 23" 4" 9" 24" Fixed Height Fixed Height w/flding PH Flding Push Handle Upper Back Tube Integral Push Handle Lwer Base Tube Straight Nn-Push Handle Integral Push Handle Flding Push Handle Omit Backtube Custmer Service: Fax: [email protected] Specificatins are subject t change withut ntice. Cpyright 25 Sunrise Medical (US) LLC. (.5) Zippie X'CAPE MK-2 REV. I Page 6

7 a Optin # HCPCS Definitin a Optin # HCPCS Definitin 7. BACKRESTS Cnt. Back Uphlstery Uph NA with Fixed Height back. Std Uph NA w/flip-up, Adj Lcking Flip-Up and Length Adj Lcking Flip-up 2BU Standard Uphlstery STD 2JB2 Backrest Name r Part # 2BU7 E26 Backrest Tensin Adj 3DX Vented $33. Width Height: 2BU7 E26 Backrest Tensin Adj Ballistic $35. 2BU66 Omit Back Uphlstery Stabilizer Bar JAY Back (Optinal) T rder any ther JAY back n-chair, please See the JAY Lst. Requires Part # JAY Bundled Backrest List NA w/ Dynamic back and Fixed Back. Only available w/integral push handle. 2SZ Stabilizer Bar $5. 8. ARMRESTS/SIDEGUARDS Armrest and Armpad - Height Adjustable Flip-Up, Adj Lcking Flip-Up and Length Adj Lcking Flip-up N/A with Std Back Uphlstery. Lw RSH in cmbinatin with large wheels may result in arm interference.spha arms NA with One arm drive. 2AA58 2AA59 2AA3 2AA29 2AA4 E973 T-Pst X-Tall(with sideguard) $265. E973 E973 2AA E973 Adjustable Lcking Flip-Up 2AA7 E973 Length Adjust. Lcking Flip-Up 2AA E973 Single-Pst Ht Adj. Std. (NA w/ 3 camber r 8"-9" frame depths) E973 T-Pst 2X-Tall(with sideguard) Flip-Up Single-Pst Height Adj. Lw (NA w/ 3 camber r 8"-9" frame depths) Omit Armrest $265. $255. $265. $285. $285. Nt available with height adjustable armrests and T-Psts 2SG33 K8 Plastic Std 2SG29 K8 Plastic Lw 2AM23 2AM24 2AM9 2AM Side Guard Armpad NA with T-Pst and Adj. Lcking Flip-Up and Fam nly avail with Length Adj. Lcking Flip-Up. Desk Classic Full Classic (NA w/"-3" Depth) Fam Shrt (nt avail. w/t Pst) Fam Lng (nt avail. w/t Pst) Pad Classic Single Pst Height Adjustable Armrest Armrest Transfer Tube Range (H) Size Length (D) STD LOW 8" 5 /4" 9 /2" t 4 /2" 8" t 2" Pad Length (L) Desk Full /4" 4" Armrest Size X-TALL 2X-TALL T-POST Range (H) 6" t 7" 7 /2" t 8 /2" Pad Length (L) 7" Custmer Service: Fax: [email protected] Specificatins are subject t change withut ntice. Cpyright 25 Sunrise Medical (US) LLC. (.5) Zippie X'CAPE MK-2 REV. I Page 7

8 a Optin # HCPCS Definitin a Optin # HCPCS Definitin 9. ACCESSORIES Back Pack (ne Backpack Black/Charcal already included) 2A 2A2 28A3 23A Black Utility Backpack $55. 2A Black Backpack Black/Charcal Kids $5. Miscellaneus Caddy (Only avail w/ Ext Mt hangers) Tl Kit $45. $45. 2A2 E227 Crutch Hlder $95. Spke Guard Psitining Belt Nt available with 2" and 6" rear wheels 2A823 E978 Belt " Dual Adj SQZ BLK PAD $85. 24A K65 Black 2A824 E978 Belt 2" Aircraft Buckle $. 24A2 K65 Clear Zippie 2A825 E978 Belt 2" Aircraft Buckle Padded $2. Designer Spke Guard 2A826 E978 Belt.5" Aut Buckle $7. Only available with 22" r 24" Spke rear wheels 2A84 E978 " Cmfrt Fit APB56 $2. 24A K65 Basketball 24A K65 Chrme Wheels Upper Extremity Supprt Tray 24A2 K65 Grafitti NA with 8"-9" widths 24A3 K65 Happy Lins 2A29 E95 X-Small (Suggested fr "-2") $25. 24A4 K65 Ht Wheels 2A3 E95 Small (Suggested fr 3"-4") $25. 24A5 2A3 E95 Medium (Suggested fr 5"-7") $25. 24A6 K65 Princess 2A32 E95 Large (Suggested fr 8"-2") $25. 24A7 K65 Space Galactica 24A8 K65 Super Her 24A9 K65 Zebra 2AT 2AO Seat Puch Anti-Tip E97 Rear Anti-Tip E97 Frnt Anti-Tip (Nt avail. with transit pt.) $45. $4. $5. $5. $5. K65 Mice n Cheese.COLOR (Standard with frame and crss brace clr chices) Frame Clr (Must chse) Standard Clrs 2C4 Aztec Gld 2C2 Black (Nt avail as base w/zebra) 2C4 Black Cherry 2C Black Opal 2C38 Blue Opal 2C36 Candy Blue 2C4 Candy Purple 2C35 Candy Red 2C42 Electric Blue 2C43 Evergreen 2C26 Glw 2C44 Green Apple 2C47 Ht Sparkle Pink 2C48 Mauve Pink 2C3 Rtbeer 2C4 Sparkle Silver 2C45 Sunrise Orange 2C3 Titanium Clr Paint 2C8 Yellw Standard Matte Clrs 2C6 Matte Black 2C5 Matte Black Cherry 2C52 Matte Purple 2C5 Matte Electric Blue 2C49 Matte Evergreen Custm Clrs (Must chse crss brace std clr) 2C43 2C42 Mssy Oak Camuflage Stars and Stripes $295. $295. 2C8 Zebra (Chse base clr abve: White Std, n/a black) $295. Crss Brace Clr Standard Clrs 2C6 Aztec Gld - Crss Brace 2C6 Black - Crss Brace 2C62 Black Cherry - Crss Brace 2C63 Black Opal - Crss Brace 2C64 Blue Opal - Crss Brace 2C65 Candy Blue - Crss Brace 2C66 Candy Purple - Crss Brace 2C67 Candy Red - Crss Brace 2C68 Electric Blue - Crss Brace 2C69 Evergreen - Crss Brace 2C6 Glw - Crss Brace 2C6 Green Apple - Crss Brace 2C62 Ht Sparkle Pink - Crss Brace 2C63 Mauve Pink - Crss Brace 2C64 Rtbeer - Crss Brace 2C65 Sparkle Silver - Crss Brace 2C66 Sunrise Orange - Crss Brace 2C67 Titanium Clr Paint - Crss Brace 2C68 Yellw - Crss Brace Standard Matte Clrs 2C69 Matte Black - Crss Brace 2C62 Matte Black Cherry - Crss Brace 2C62 Matte Purple - Crss Brace 2C622 Matte Electric Blue - Crss Brace 2C623 Matte Evergreen - Crss Brace Additinal Optins Thrugh Built fr Me T inquire abut any unique custmizatin fr Quickie prducts, cntact: Phne: (8) 333-4, Fax: (8) Cmmnly Requested Optins Include: Slid Seat Grade Aid Drum Brake Custmer Service: Fax: [email protected] Specificatins are subject t change withut ntice. Cpyright 25 Sunrise Medical (US) LLC. (.5) Zippie X'CAPE MK-2 REV. I Page 8