S646 Order Form - Quickie-Wheelchairs.com

QUICKIE S646 SE BD/SD/MPDNo Power, Single Power & Multi Power Seating OptionEIS62 - Effective May 2012Account:Date:PO#:Buyer:Marked For:Ship To:Name:Address:City,State,Zip:Phone: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.Option # HCPCS DefinitionPriceOption #HCPCSDefinitionPrice1. QUICKIE S646 SE BD/SD/MPD POWER CHAIRThe Inclusion of the previous power wheelchair HCPCS code, K0014, is specifically for those payers that have not adopted thenew HCPCS codes for power mobility devices released by CMS in 2006.105PC90K0868K0014Quickie S646 SE BD PowerQuickie S646 SE BD$6,499.00105TO25Transit4 Point Transit Package $300.00Power Seating System TypeSee electronic section for control options105LB1 0 to 250 lbs N/C105LB5251 to 300 lbsN/CSuspension105SV01Up to 175 lb Weight CapacityN/C105SV02176 to 250 lb Weight CapacityN/C105SV10251 to 300 lb Weight CapacityN/CPerformance Package105PF948.5 mph / 300 LB Capacity N/CLED Light Package (Requires Rne t)105LI04LED Light Package(NA w/recline or Base only)$1,000.002. POWERED SEATING105PT1105PT4E1002E1008Power Seating System OptionsPower CG Tilt - 53°50° Tilt Recline w/Pwr Shear Reduction(MPD Only)$4,995.00105PT3 E1005 Power Recline System / Pwr Shear$5,320.00$9,620.00MPD base can be ordered with any of the above power seating options at initial issue.Expandable controls are required with all MPD BasesPowered Seat Option Electronics105EO1 - Standard Toggle Switch Activation(select switch on page 4)105TN1 - Toggle Mount Right105TN2 - Toggle Mount Left105EO3 E2310 Thru Drive 1 Actuator105EO5 E2311 Thru Drive 2+ ActuatorsN/CN/CN/C$1,375.00$2,825.00ORDERING INFORMATION PHONE: (800) 236-4215, FAX: (602) 279-0952, WEBSITE: www.southwestmedical.comPage 1

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.Option # HCPCS DefinitionPriceOption #HCPCSDefinitionPrice5. BACKS 105BU27Parapak Upholstery (select back height)N/C 105BU26 K0669 Jay Solid Backrest (select back height) N/C 105BU35 E0956 Jay Precision Back Tall w/ Laterals $345.00 105BU42 Jay Precision Back Tall omit Laterals $345.00 105KE22 E0956 Lateral Pad Symmetric Swing Away (Not $340.00E1028 avail. w/ push handles and backrest orBack pad.) 105KE20 E0956 Lateral Pad Symmetric$190.00 105KE19 E0956 Lateral Pad Asymmetric$190.00 105KE21 E0956 Lateral Pad Asymmetric Swing Away$340.00E1028 105BU14 Omit Jay Solid Backrest (This optionshould be selected only when using a Jay3 or other aftermarket backrests incombination with tilt seating.)Jay 3 Option105JB01 -Back TypeJay J3 (select OMIT Backrest above)(15.00)See J3 OF21"-29" Only available on Reclining and Tilt and Recline Systems.When selecting 21"-29with the Smart Seat only there will be a 7" gap btwn the seat pan & the bottom of thebackrest pad when the shear adj. is fully extended. This provides room for the shearcompensation to operate.Back Height105B88 15" - 16"N/C105B95 17" - 18"(Not avail. on Pwr Recline or Tilt& Recline)N/C105B97 19" - 20"N/C105B99105B100105B112 25" - 26"105B11327" - 28"105PN1105PN221" - 22"N/C23" - 24" N/CSeat TypeSeat Pan AluminumOmit Seat Pan (not avail. w/Recline Seat)Power Recline Back Preset Home Angle 90° 105QK1 95° 105QK2 100° 105QK3N/CN/C105B114 29" N/CN/C($45.00)105CU1105JC05105JC03105JC09105JC10105JC11E2622E2623E2605E2606E2603E2604E2607E2608E2607E26092" Cushion.Jay J2 Deep ContourJay Soft Combi PJay GO6. SEAT CUSHIONS$95.00See JAY OFSee JAY OF105JC04105JC07105JC02E2622E2623E2622E2623E2607E2601E2602Jay J2Jay J3Jay EasyJay BasicJay ION See JAY OF 105JC08 E2607 Jay ZIPJay UNIONSee JAY OFSee JAY OF105JC01See JAY OFSee JAY OFSee JAY OFSee JAY OFSee JAY OF7. ARMRESTSArmpads - Non Reclining (Pair) 105AM7 Desk Length Waterfall (10") (not avail. onN/CReclining Height Adjustable Armrest) 105AM8Full Length Waterfall (14") (not avail. onN/CReclining Height Adjustable Armrest) 105AM1Desk Length Standard (10") (not avail. on $15.00Reclining Height Adjustable Armrest)105AA30105AA40105AA8105AA60105AA14E0973E0973Dual Post Flip Back Height Adj.Single Post Height Adjustable105AA60 E0973 Reclining Height Adjustable ( Onlyavailable on Reclining and Tilt and ReclineSystems. )Std Height (9" - 12")105AA61 Tall Height (11" - 14")105AM2Armrest (Pair)Dual Post Flip BackOmit ArmrestsFull Length Standard (14") (not avail. onReclining Height Adjustable Armrest)N/C$250.00$260.00N/CN/CN/CN/C$15.00105AM17105AM18105AM19Armpads - Reclining (Pair)Only available on Reclining and Tilt and Recline SystemsK0106 Otto Bock Med forearm pads (11")K0106Reclining Arm Pad (16")Otto Bock Lg forearm pads (13")Otto Bock Hand Pads (Pair)$240.00$240.00To be used with Otto Bock Forearm Pads. Only available on Reclining and Tilt andRecline Systems.N/C105OB02 E2209 Medium Flat Hand Pads (4-1/2"x 7") $105.00105OB01 E2209 Large Flat Hand Pads (5-1/2"x 9") $105.00ORDERING INFORMATION PHONE: (800) 236-4215, FAX: (602) 279-0952, WEBSITE: www.southwestmedical.comPage 3

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.Option # HCPCS DefinitionPriceOption #HCPCSDefinitionPrice8. FOOTRESTS105H2105H37Hanger (Pair)70° Swing Away Hanger90° Swing Away (Only available with kidsangle adjustable footplates)N/CN/C105F282 K0040 Adult Angle Adjustable Footplate $165.00105HL10Foot Plate (Pair)Adult Angle Adjust. w/ heel loopKids Angle Adj. w/ Leg Strap (Only available with 90°hangers)$210.00E0951 Heel Loop $45.00$195.00105H14105H38105H39E0990E1010E1010Manual Elevating Hanger (Req.aluminum footplate or angle adj. andMed. Extension Tubes)Power Elevating (Pair) Order withPower ELR/ALR extension tubes.Maximum rider weight limit 250 lbs.Only available with seat widths 16"and greater.Power Articulating (Pair) Order withPower ELR/ALR extension tubes.Maximum rider weight limit 250 lbs.Only available with seat widths 16"and greater.$280.00$1,440.00$1,880.00105F283105LS13 K0038 Leg Strap105F61105HL10E0951Heel Loop $45.00Multi-Positional w/Heel LoopNot avail. w/med. Ext. tubes. Avail. for use only on the 70°swing-away hanger and the Power ALR and ELR.105F47105HL10105F6K0040K0040 Two-piece Locking Footplate $165.00K0040E0951Kids Angle Adjustable Footplate105F5 K0042 Aluminum (Only avail. w/manual ELR)Two-piece Locking w/Heel Loop (Only avail. w/ 70° SAHangers)Multi-Positional FootplateHeel LoopOmit Foot Plate w/Heel Loop$165.00$30.00$30.00$210.00$215.00$170.00$45.00N/C105H32105E1105E2Omit HangersExtension TubeNot available with 90° hangers.Short (13" - 15")Medium (15" - 18") Not availablewith multi-position footplate.($15.00)N/CN/C105LS3105A110K0038E0952Footrest AccessoriesExtra Leg Strap, BlackToe Loop (Only available with angleadjustable footplates)$30.00$45.00105E5 Long (18" - 20")105E33Power ELR/ALR Med (15.5" to 18")Use Multi-positional Footplates for shorterleg lengths (13" - 15-1/2").N/CN/C105E34Power ELR/ALR Long (17.5" to 20")N/CORDERING INFORMATION PHONE: (800) 236-4215, FAX: (602) 279-0952, WEBSITE: www.southwestmedical.comPage 4

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.Option # HCPCS DefinitionPriceOption #HCPCSDefinitionPrice9. ELECTRONICSDrive ControlR-net OMNI and Output Options 105J57 - 90A VR2 Non-Expandable ControllerSTD 105J91 - Omni* Only$975.00 105J89 E2373 Compact Joystick with Omni*$1,050.00Drive Controller Upgrade Options 105J90 Output Module w/ Omni*$1,050.00 R-Net Expandable Drive Control Upgrade (90A) $950.00 105A401 E2351 Output Module w/o Omni* (ECM)$995.00105EX01 E2377 Expandable Controller - R-net$525.00 105A602 - Rnet Bluetooth Mouse-mover $850.00105EX02 E2313 Harnessing for Expandable Controller $425.00* Omni is always mounted on the opposite side of the joystickR-net Joystick and Expandable Options 105J70 - Std LED Joystick for Expandable Ctrls N/C 105J93 - Joystick w/mono jacks$200.00and monochrome display105J88 - Joystick W/Toggle, Spd Pot & Color Disp. $395.00Joystick Mount (Fixed or Swing Away)105JM1 - Fixed MountN/C105JM2 E1028 Swing Away Mount$235.00Joystick Mount (Location)Height Adjustable.105HM1 - Right Side MountN/C105HM2 - Left Side Mount N/CJoystick Handle105JH1 E2323 Ball Handle $75.00105JH2 E2323 Foam Ball Handle $75.00105JH4 E2323 T-Handle$75.00105JH6 E2323 Goalpost $75.00Addition of Second Joystick to Specialty Input105J88105A404-E2351Joystick w/Toggle/Speed Pot /Color Disp.2nd Output module for additional ports$395.00$1,050.00OMNI Mount (If used with Joystick must be mounted opposite side) 105DK2 - Left Side MountN/C 105DK1 - Right Side MountN/CBattery Charger 105BJ198 A Battery Charger CTEN/C 105BJ3 Omit Charger-$40.00Batteries 105A47 E2361 Battery 22NF Gel Pair $320.00 105A48 E2363 Battery GP-24 Gel Pair (for best range) $390.00Battery Straps 105BK2Battery Strap and Insert 22NFN/C 105BK1 Battery Strap GP-24 N/C10. SPECIALTY INPUT INDIVIDUAL COMPONENTSSpecialty Input Device - Requires USDM105ID6 CA-5 Interface Box $150.00105ID9Mini Proportional Joystick$780.00105ID10 Penta Switch$200.00Specialty Input Device - Single Switch105SW1 Buddy Button Switch $75.00105SW2 Disc Switch $160.00105SW10 Egg Switch-Black $95.00105SW4105SW6105SW9105SW11Specialty Input Device - Single Switch (cont)Micro Light SwitchRibbon Switch $95.00Wobble SwitchSwitch Mount Bracket (Not availablewith wobble switch)$75.00$500.00$195.00ORDERING INFORMATION PHONE: (800) 236-4215, FAX: (602) 279-0952, WEBSITE: www.southwestmedical.comPage 5

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.Option # HCPCS DefinitionPriceOption #HCPCSDefinitionPrice11. POSITIONING OPTIONSSolid backrest must be selectedHeadrest (Included on Specified Specialty Controls)Headrest (Included on Specified Specialty Controls)Headrest 8" x 4.5" $495.00 Headrest 9" x 4.5" $495.00105HE1 E0955 Curved Headrest 8" x 4.5"$270.00105HE2 E0955 Curved Headrest 9" x 4.5" $270.00105MH1 E1028 Removable Mount$225.00105MH1 E1028 Removable Mount $225.0012. LATERAL THORACIC SUPPORTRequires Jay Solid BackrestPad StylePad SizeLateral Pads Curved$450.00 105KD1 Lateral Support 3" x 6" (pr) N/C105KE1 E0956 Lateral Pad Curved Pair$225.00 105KD2 Lateral Support 4" x 5" (pr) N/C105LM1 E1028 Swing Away Mount Pair$225.00 105KD3Lateral Support 4" x 6" (pr)N/CLateral Pads Straight$440.00105KE2 E0956 Lateral Pad Straight Pair $215.00105LM1 E1028 Swing Away Mount Pair $225.0013. WHEELSDrive WheelWheel Lock105DW14 14" Cast Wheel Pneumatic Tire N/C105WL8 Push to Lock $85.00105DW15 14" Cast Wheel Pneumatic w/Ins. N/C105WL12Do Not MountN/C105DW2414" Chrome/Black Whl Pneumatic $140.00105DW2514" Chrome/Black Pneumatic w/Ins. $140.00Drive Wheel Tire105DT1 Knobby STD14. CASTERSRear Caster WheelCaster Fork105RK1 4" Soft Polyurethane N/CSuspension Fork Options are only available with 8" casters.105RK24" Micro Lighted $60.00 105CF31 Solid Caster Fork N/CFront Caster Wheel105CF34105CF35E1016E1016Suspension Fork Light 0-150 lbs.Suspension Fork Med. 151-250 lbs.$260.00$260.00105CW20 8" Pneumatic w/ Insert N/C 105CF43 E1018 Suspension Fork Heavy 251-300 lbs. $260.00105CW218" PneumaticN/C105CW28 9" Pneumatic w/Insert $85.00105CW299" Pneumatic$85.00ORDERING INFORMATION PHONE: (800) 236-4215, FAX: (602) 279-0952, WEBSITE: www.southwestmedical.comPage 6

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.Option # HCPCS DefinitionPriceOption #HCPCSDefinitionPrice15. ACCESSORIESWheelchair Tray Table (Size based on seat width chosen)Specialty Driver Control Options (requires expandable controls)Note: Available only with Std armpads 14-20"All packages must be added to the specialty control on-chair package. 105A31 E0950 Medium Tufftak (15"-17-") $250.00 Not available with Upholstered backs 105A32 E0950 Large Tufftak (18"-20") $250.00 Quickie Sip n' Puff System105ID26 E2325 Sip N' Puff KitBackpack105EA3 E0955 Headrest 105A1 Black Utility $55.00105EA1 E1028 Headrest Removable Mount 105A2 Black/Charcoal Kids $50.00105EA4 E2326 Sip n' Puff Tubing and Hardware$2,795.00$1,870.00$265.00$210.00$450.00Positioning Belt - Select for any style seat ASL Head Array Package (Adult) 105A142 1.5" Auto Style Buckle N/C105ID31 E2330 ASL Proximity Head Array (Adult) 105A12 E0978 Belt 2" Aircraft Buckle $110.00105EA1 E1028 Headrest Removable Mount 105A13 E0978 Belt 2" Aircraft Buckle Padded$120.00 ASL Head Array Package (Ped)Electronic Programmers105ID30 E2330 ASL Proximity Head Array (Ped) 105PR2VR-2 Hand Held Programmer (HHP)$250.00105EA1 E1028 Headrest Removable Mount105PR3105PR4R-net PC Programmer with DongleR-net Hand Held (DTT)$400.00$1,000.00 Switch-It Head Array Package (Adult)105ID13 E2330 Switch-it Proximity Head ArrayAttendant Control105EA1 E1028 Headrest Removable Mount105A465105A450E2331E2331Attendant Control for VR-2Attendant Control for R-net$995.00$995.00 Switch-It Head Array Package (Pediatric) 105DN1 MOUNTING LOCATION: Right Back Cane N/C105ID14 E2330 Switch-it Proximity Head Array 105DN2MOUNTING LOCATION: Left Back CaneN/C105EA1 E1028 Headrest Removable Mount$5,795.00$5,585.00$210.00$5,795.00$5,585.00$210.00$4,390.00$4,180.00$210.00$4,390.00$4,180.00$210.00Single Switch (pick a switch to operate your tilt or recline with toggle HMC Proportional Mini Joystick Chin/Lip Control Pkg. $4,595.00 105SW6Ribbon Switch $95.00105ID28 E2312 Mini Joystick$4,120.00 105SW1 Buddy Button Switch $75.00 105EA3 E0955 Headrest$265.00 105SW2 Disc Switch $160.00105EA1 E1028 Headrest Removable Mount$210.00 105SW9Wobble Switch $500.00 105SW4Micro Light Switch $75.00 HMC Proportional Mini Joystick Midline w/Gatlin Pkg.$4,595.00 105SW10Egg Switch-Black $95.00105ID32 E2312 Mini joystick$4,385.00105EA5 E1028 Swing Away Mount$210.00Single Switch Mount Bracket 105SW11Switch Mount Bracket $195.00 Proportional Chin Control Package$3,795.00105ID12 E2312 Proportional Joystick$3,585.00Seat Pouch105EA1 E1028 Removable Mount$210.00 105A8Black/Charcoal $45.00Miscellaneous105A82 Caddy $45.00Weight:Overall WidthOverall Length:Range:105VT2Top Speed:E1030128 lbs (without batteries)29-1/2" (Without Footrests)Up to 8.5 mphVent OptionsArticulating Vent Tray $1,395.00Additional Specifications25-3/4" (Standard Width Base); 27-3/4" (Wide Base)(Measured at drive wheels)As far as 16.2 miles (With Group 24 batteries dependingon conditions and user environment)ORDERING INFORMATION PHONE: (800) 236-4215, FAX: (602) 279-0952, WEBSITE: www.southwestmedical.comPage 7