Quickie All Court® EISP1, Effective January 2016 ACCOUNT INFORMATION Account No: ___________________________________________________________________________________ Drop Ship/Ship To: _________________________________________________ Date: ________________________________________________________________________ Name: ___________________________________________________________ P.O. #: ________________________________________________________________________ Address: _________________________________________________________ Buyer: _________________________________________________________________ City: _________________________________________________________ State:______________________ Marked For: _________________________________________________________________________ Zip Code:_____________________________ Phone Number:_________________________ The HCPCS codes provided are based on code verification by the PDAC or our interpretation of the code definitions. Proper use of HCPCS codes does not ensure coverage or payment. For coverage information, verify the appropriate payor's coverage policy. 1. FRAME 155WM14 Base Frame 155BF01 155BF02 155BF03 Base Model New All Court Model Standard Single Intergral Anti-Tip Dual Integral Anti-Tip $2,695.00 Frame Type 155FT6 155FT57 Basketball Single Wing BB Single Wing W/Stand Up NC $100.00 NC NC $100.00 Includes 5th Wheel Support at No Charge 2. SIZE / SEATING Frame Length 155FL50 SEAT MATRIX Frame Length Short 15" NC NA w/ 17-20" Seat Depth 155FL51 Frame Length Medium 17" NC NA w/ 10-11" or 19-20" Seat Depths 155FL52 155FL53 Frame Length Long 19" Frame Length X-Long 21" Seat Width (See Seat Matrix) 155S3 12" Seat Width 155S4 13" Seat Width 155S5 14" Seat Width 155S6 15" Seat Width 155S7 16" Seat Width 155S8 17" Seat Width 155S9 18" Seat Width 155S10 19" Seat Width 155S47 20" Seat Width NC NC NC NC NC NC NC NC NC NC NC 155SL1 155PN5 SEATING OPTIONS Seat Sling Standard Seat Pan Half Deep Cushion 155CU1 Cushion 2" Front Seat Height 155SH14 155SH16 155SH18 155SH21 155SH24 155SH27 16" Front Seat Height 17" Front Seat Height 18" Front Seat Height 19" Front Seat Height 20" Front Seat Height 21" Front Seat Height NC $70.00 $120.00 Optional Seat Width 1/2" Seat Width is built-in when selecting Aluminum Side Guards 155OW1 1/2" Seat Width Seat Depth (See Seat Matrix) 155SD3 10" Seat Depth 155SD4 11" Seat Depth 155SD5 12" Seat Depth 155SD6 13" Seat Depth 155SD7 14" Seat Depth 155SD8 15" Seat Depth 155SD9 16" Seat Depth 155SD10 17" Seat Depth 155SD11 18" Seat Depth 155SD12 19" Seat Depth 155SD73 20" Seat Depth NC NC NC NC NC NC NC NC NC NC NC NC ORDERING INFORMATION PHONE: (800) 333-4000, FAX: (800) 300-7502, WEBSITE: www.sunrisemedical.com Specifications are subject to change without notice. Copyright @ 2009, Sunrise Medical. Quickie All Court - Page 1 of 3 MK-100026 REV B NC NC NC NC NC NC Quickie All Court, September 2015 3. CASTERS Caster 155CW1 3" Micro NC 4. REAR WHEELS Rear Seat Height 155RH11 155RH13 155RH15 155RH17 155RH19 155RH20 155RH21 155RH22 155RH23 13" Rear Seat Height 14" Rear Seat Height 15" Rear Seat Height 16" Rear Seat Height 17" Rear Seat Height 18" Rear Seat Height 19" Rear Seat Height 20" Rear Seat Height 21" Rear Seat Height NC NC NC NC NC NC NC NC NC Rear Wheel Tire 155RT31 155RT5 Handrim 155HR1 155HR4 155HR7 Handrim Tab 24" X/S Spoke Wheel (540) 24" X/S QP HT Tnns (559) 24" X/S QP HT BB (559) 26" X/S QP HT BB Wheel (590) 26" X/S QP HT BB Whl (700C) 24" Spinergy Whl 540 Blk 24" Spinergy Whl 559 Blk 26" Spinergy Whl 590 Blk Omit Rear Wheel & Axle (540) Omit Rear Wheel & Axle (559) Omit Rear Wheel & Axle (590) Omit Rear Wheel & Axle (700C) NC $275.00 $275.00 $275.00 $275.00 $795.00 $795.00 $795.00 NC NC NC NC Aluminum Handrim Anodized Plastic Coat Handrim Omit Handrim NC NC NC $95.00 NC Only avaialble with cross spoke (x/s) wheels 155TB1 Rear Wheel 155RW53 155RW69 155RW70 155RW66 155RW72 155RW57 155RW59 155RW61 155RW63 155RW64 155RW65 155RW71 High Pressure Clincher Tire Turbo Tread Tire Camber Tube 155CI10 155CI11 Handrim Regular Tab NC 16 Degree Camber 20 Degree Camber NC NC Axle 155AX4 155AX11 QR Steel Quad QR Axles NC $90.00 x` 5. FOOTREST Footrest Adaptive Platform Spacer 155F234 155F39 Footrest Options 155IG20 Platform High Mount Platform NC NC Neoprene Impact Guards NC NA w/ High Mount Platform Footrest 155AD1 155AD2 155AD3 Adaptive Platform 2" Spacer Adaptive Platform 4" Spacer Adaptive Platform 6" Spacer $95.00 $95.00 $95.00 Back Upholstery Std Back Upholstery Adj Sports Back Upholstery Omit NC $150.00 -$15.00 6. BACKREST / SEATING Back Type 155BT1 155BT3 Folding Backrest Non Folding Backrest NC NC Back Height 155B128 155B133 156B83 155B134 155B135 9" Fixed 10 - 13" Fixed 12 - 16" Fixed 15 - 18" Fixed 17 - 20" NC NC NC NC NC Back Upholstery 155BU1 155BU13 155BU14 7. SIDE GUARDS Side Guard 155SG4 155SG3 155SG5 Plastic Side Guard Kids Plastic Side Guard Reg Alum Side Guard Reg $125.00 $125.00 $175.00 Alum Side Guards required for the 1/2" seat width option ORDERING INFORMATION PHONE: (800) 333-4000, FAX: (800) 300-7502, WEBSITE: www.sunrisemedical.com Specifications are subject to change without notice. Copyright @ 2009, Sunrise Medical. Quickie All Court - Page 2 of 3 MK-100026 REV B Quickie All Court, September 2015 8. KEY OPTIONS AND ACCESSORIES Anti-Tip 155AT39 155AT40 Rear Anti Tip Integral Rear Anti Tip Quick Release NC $90.00 Backpack 155A1 155A2 Black Utility Backpack Back Pack Blk/Charcoal Kids $55.00 $50.00 Seat Pouch 155A8 Seat Pouch Black/Charcoal $45.00 Positioning Belt 155A17 155A18 155A190 155A191 Hook & Loop Closure Nylon Buckle Closure Ratchet Pos Belt Lrg Ratchet Pos Belt X-Lrg $60.00 $60.00 $90.00 $90.00 Spoke Guard 155A24 155A23 155A25 Spoke Guard - Clear Spoke Guard - Black K0065 Spoke Guard Sport Hi-Profile K0065 K0065 $115.00 $115.00 $120.00 Only available in Black 155A26 K0065 Spoke Guard Sport Low-Profile $120.00 Only available in Black Chest Straps 155A103 155A106 Accessories Misc 155A90 Chest Strap 2" (48" Length) Chest Strap 4" (48" Length) $30.00 $40.00 Pad For Backrest Crossbar $30.00 Required for Tournament play 155A98 155A180 155A181 Tire Pump Toe Clips 5th Wheel Support $80.00 $50.00 $110.00 MATTE FRAME COLOR 155C116 155C151 155C150 155C149 155C152 Matte Black Matte Black Cherry Matte Electric Blue Matte Evergreen Matte Purple NC NC NC NC NC 9. COLOR FRAME COLOR 155C140 155C2 155C141 155C10 155C38 155C36 155C14 155C35 155C142 155C143 155C126 155C144 155C147 155C148 155C103 155C114 155C145 155C113 155C8 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 Applie Hot Sparkle Pink Mauve Pink Rootbeer Sparkle Silver Sunrise Orange Titanium Color Paint Yellow NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC CUSTOM FRAME COLOR 155C112 Desert Camouflage 155C43 Mossy Oak Camouflage 155C42 Stars & Stripes 155C108 Zebra (Choose above base color) $295.00 $295.00 $295.00 $295.00 Std with White unless above base paint is chosen NA w/ Blck, Matte Black, Blck Opal or Titanium ORDERING INFORMATION PHONE: (800) 333-4000, FAX: (800) 300-7502, WEBSITE: www.sunrisemedical.com Specifications are subject to change without notice. Copyright @ 2009, Sunrise Medical. Quickie All Court - Page 3 of 3 MK-100026 REV B