GP/GPV Order Form - Quickie-Wheelchairs.com

aMark For: Submitting for: o Quote o OrderDate:Dealer Acct #:Dealer:Dealer Contact:Dealer Address:Dealer City:ST:Dealer Phone: ( ) Fax: ( )Confirmation Email:Confirm Via:PO#:ZIP:Quickie GP/GPVNovember 2012EIGP70Address:o Fax o EmailShip To Phone: ( ) Fax: ( )Option # HCPCS aDefinition Price Option # HCPCS Definition Price1. FRAME STYLEShip To:Attention:Address:Ship To City:ADDITIONAL SHIPPING INFORMATIONThe 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.ST:ZIP:o 024WM23 K0005 Quickie GP-70° $1,015.00o024WM23K0005 Quickie GPV-70° (NA 12"-13") $1,015.002. FRAME STYLE & SET UPoooooooooooooooooooooooooooFrame Angle024FA6 o 60°NC024FA770° NC024FA1 o 75° (NA with rigid footrest) NC024FA8 o 80° (NA with rigid footrest) NCFrame Color024C2 Black NC024C10 Black Opal NC024C38 Blue Opal NC024C36 Candy Blue NC024C14 o Candy Purple NC024C35 Candy Red NC024C128 Copper NC024C6 Forest Green NC024C127 o Fuchsia NC024C126 o Glow NCo Matte Black024C116 NC024C117 o Matte GreenNC024C4 o Midnight PurpleNC024C5 o Pearl PinkNC024C103 o Rootbeer NC024C114 o Sparkle Silver NC024C113 o Titanium Color Paint NC024C11 o Toxic Green NC024C8 o YellowNCCustom Frame Color024C112Desert Camouflage $295.00024C43 Mossy Oak Camouflage $295.00024C42Stars & Stripes $295.00024C108Zebra (Choose above base color) Stdwith White unless above base paint ischosen NA w/ Black$295.00Xtender Power Assist024XT1 E0986 Rear Seat Height 16.75" $6,595.00You must choose one of the following torque options024XH1 3x Torque Multiplier (Plastic Coated) NC024XH21.5x Torque Multiplier (Stainless Steel) NCo024XW1E2211E2212Xtender - Tire OptionPneumaticXtender - Other Options024XA1 Spare NiMH Power Pack $1,395.00Frame WidthSeat Width 1/2" Narrower024W312" NC024W413"NC024W514"NC024W615"NC024W716"NC024W817"NC024W918"NC024W1019"$125.00024W11 E2201 20"$450.00024W12 E2201 21"$450.00024W13 E2201 22"$450.00NCORDERING INFORMATION PHONE: (800) 236-4215, FAX: (602) 279-0952, WEBSITE: www.southwestmedical.comPage 1

2. FRAME STYLE & SET UP (CONT.)oooooooooooSling Depth024SD5 o 12"NC024SD6 o 13" NC024SD7 o 14" NC024SD8 o 15"NC024SD9 o 16" NC024SD10 o 17"NC024SD11 o 18" NC024SD72 o 19" $75.00024SD13 oE2203 20" $475.00024SD14 oE2203 21" $475.00024SD33 oE2204 22"$795.00Frame Length024FL30 18-1/4" (Avail. on 12" Sling Depth) NC024FL31 19-1/4" (Avail. on 13" Sling Depth) NC024FL32 20-1/4" (Avail. on 14",15" Sling Depth) NC024FL3321-1/4" (Avail. on 14",15",16" Sling Depth) NC024FL3422-1/4" (Avail. on 16",17" Sling Depth)NC024FL3523-1/4" (Avail. on 17",18" Sling Depth)NC024FL3624-1/4" (Avail. on 18" Sling Depth)NC024FL3725-1/4" (Avail. on 19" Sling Depth)NC024FL3826-1/4" (Avail. on 20" Sling Depth) NC024FL3927-1/4" (Avail. on 21" Sling Depth)NC024FL4028-1/4" (Avail. on 22" Sling Depth)NCoooFrame Height (See Chart)024FH2Short (front 9.25"-rear 8.25")NA with Xtender Power Assist$110.00024FH5 Standard (front 10" - rear 9") NC024FH7 Tall (front 11" - rear 10")$110.003. SEATINGoooooooooooooooooooBack Type024BT3Non-Folding Backrest (Fixed)NA with push handles or adj. upholstery024BB1 8" Back Height NC024BB2 9" Back Height NC024BB3 10" Back Height NC024BB4 11" Back Height NC024BB5 12" Back Height NC024BB6 13" Back Height NC024BB7 14" Back Height NC024BB8 15" Back Height NC024BB9 16" Back Height NC024BT1Folding Backrest (Adjustable)024BA1 11" - 14" Back Height $65.00024BA2 12" - 16" Back Height $65.00024BA3 o 14" - 18" Back Height$65.00024BA4 o 16" - 20" Back Height$65.00Back Upholstery024BU1StandardNC024BU8 Adjustable $175.00024BU16 Reinforced (NA w/ adj. upholstery) $30.00024BU14 Omit Back Upholstery -$15.00oooooooBackrest Options024BT33 Folding w/ Integral Push Handles NC024A85Bolt-On Push Handle (Folding only)NA with Xtender Power Assist$115.00024SR2024SR3Regular Stroller HandleNA with amputee axle plate or XtenderPower AssistTall Stroller HandleNA with amputee axle plate or XtenderPower Assist$125.00$125.00JAY Back (Optional)024JB01 J3 Back (See J3 Order Form) Price ListCushion024CU9 Reinforced Seat Sling $30.00024CU1 K0669 2" Cushion $95.00024CU2Omit CushionNC024CU4 Omit Cushion and Seat Sling -$15.00JAY Bundled Cushions - OptionalTo order any JAY cushions on-chair, please see JAY Price List. Cushion nameor part number must be filled out with desired width & depth.JAY Bundled Cushiono 024JC20 Cushion Name or Part #:Price ListWidth:Depth:4. ARMRESTo024AA9 E0973oooo024AM1 o024AM2o 024AA8 E0973024AM1024AM2Single PostPadded Swing Away ArmrestSingle Post Ht. Adjust. LowAll Padded Swing-Away NA with amputee axle plate or Xtender Power Assist$260.00Must be removed to fold back downo 024AA19 E0973 Padded S-A Medium $175.00Desk Length - Classic (10") NC 024AA16 E0973 Padded S-A Adult $175.00Full Length - Contour (14")NCSingle Post Ht. Adjust. StdMust be removed to fold back down$260.00Desk Length - Classic (10")NCFull Length - Contour (14")NCORDERING INFORMATION PHONE: (800) 236-4215, FAX: (602) 279-0952, WEBSITE: www.southwestmedical.comPage 2

FootplatesHeel loop or leg strap not included, See Footplate Options Section1. GP FOOTREST OPTIONSRigid NA w/ Ext. Tubes; NA with 75° oro 024F56 K0040 NC80° frame angleoo024F50 K0040 Platform NA w/ Ext. Tubes $95.00024F1 K0040 Composite Footplate NC5. FOOTRESTo 024F3 K0040 Adult Angle Adj.$185.00Footplate Options (Ext Tube & Direct Mount)o 024F48 oK0040 Platform Flip Up$190.00024HL1 E0951 Heel Loop $30.002. GPV FOOTREST OPTIONSo 024HL5 K0038 Leg Strap$35.00Rigid NA w/ Ext. Tubes; NA with 75° oro 024HL4Omit Heel LoopNCo 024F56 K0040 NC80° frame angleo 024HL6Omit Leg StrapNCo 024F50 oK0040 Platform NA w/ Ext. Tubes $95.00024F7Omit Footplate & Ext Tube-$15.00o 024F48 oK0040 Platform Flip Up $190.00 024IG2 Impact Guard Neoprene $85.00ooo6. CASTERSFootrest Extension Tubes024E1Short (14" to 16-1/2")NC024E2 Medium (16-1/2" to 19") NC024E5 Long (19" to 21-1/2") NCo 024E16 K0037High Mount Only avail. with adultangle adjustable footplates$55.00ooooooooooCaster Wheels024CW1 3" Micro NC024CW3 4" Low Profile Polyurethane NC024CW31 4" Micro Lighted $70.00024CW6 5" Soft Roll Semi-Pneumatic $85.00024CW5 5" Low Profile Polyurethane NC024CW75" x 1.5" Semi-Pneumatic only avail.For use in bottom fork holes$85.00024CW33E2214E22156" Pneumatic$75.00024CW34 o 6" Polyurethane NC024CW356" x 1.5" Semi-Pneumatic only avail.For use in bottom fork holes$85.00024CW21E2214E22158" PneumaticOnly available on 60° frame option$75.00oooooo024CW32024CW36024CW22E2214E2215E2214K0108Caster Wheels - Continued8" PolyurethaneOnly available on 60° frame option8" x 2" PneumaticOnly available on 60° frame option8" x 2" Pneumatic w/Airless InsertOnly available on 60° frame option$225.00Caster Fork Options024CS5 3/4" Longer Fork Stem Bolt NC024CS9 1-1/2" Longer Fork Stem Bolt NC024CS3 K0073 Caster Pin Locks $195.00024CW12 Omit Casters NCNC$145.007. AXLE & WHEEL OPTIONSAxle PlateN/A w/ Power Assistoo024AL2024AL13Standard AdjustableDouble Slotted AdjustableNC$60.00o 024AL6 E0959Amputee Adjustable NA with paddedswing-away armrests or stroller handles$175.00ooo024AX1024AX11024AT1ooE0971AxleQuick Release SteelQuad Quick ReleaseRear Anti-TipRear Anti-TipRear Wheel TypeNC$90.00$135.00Spinergy NA w/ Xtender, spoke guards. Contact Built 4 Me for Spinergy Color Optionso 024RW8 o 22" Mag (NA with Xtender Power Assist)NCo 024RW9 o 22" Spoke (NA with Xtender Power Assist) $200.00ooo024RW1024RW2024RW11 o24" Mag24" Spoke26" Spoke (NA with Xtender Power Assist)NCNC$65.00o 024RW42 o 24" Spinergy (540) SPOX Black $695.00o 024RR25Omit Rear Wheel and Axle -$55.00Intended Size for Set Up :oo024RT1024RT2E2211E2212E2211E2213Rear Wheel TirePneumatic NCPneumatic Airless InsertNA with 26" wheels$80.00Rear Wheel Tire (Continued)Full Poly (24" Only)o 024RT3 E2218NA with 26" wheelsooProjection Hand RimProjections NA w/ plastic coated handrimso 024HR8 8 Oblique (24"/26") $240.00oo024RT6E2211E2212High-Pressure Clincher NA w/ 26", N/Cw/ Performance$95.00Hand Rim024HR1Aluminum AnodizedNC024HR4 Plastic Coated -NA on all rims $95.00024HR7Omit Hand RimNC024WL1024WL2024WL5024WL12 Do Not Mount Wheel Locks NC024WL10 Omit NCExtension Handle024EH1 E0961 6" Pair $75.00o 024GA1 E0974Wheel LockHigh Mount PushHigh Mount PullHigh Mount Scissor NA w/ extensionhandles, grade aidesGrade AidGrade Aid NA w/ poly, high-pressureclincher tires, or XtenderNCNCNCNC$150.00ORDERING INFORMATION PHONE: (800) 236-4215, FAX: (602) 279-0952, WEBSITE: www.southwestmedical.comPage 3

8. KEY OPTIONS & ACCESSORIESooooooo024A1024A2ooBackpackQuickie Backpack BlackQuickie Kids Backpack BlackSeat Pouch024A8 Quickie Seat Pouch Black $45.00Crutch Holder024A53 oE2207 Left Side $195.00024A52 E2207 Right Side $195.00Extra Leg Strap024A55 K0038 Extra Leg Strap BlackMiscellaneous024A83 o Tool Kit $45.00Positioning Belts$55.00 024A141 E0978 Belt 1.5" Auto Buckle w/Clamps$70.00$50.00024A117 E0978 Belt 2" Aircraft Buckle w/Clamps $110.00o 024A118 E0978 Belt 2" Aircraft Buckle Pad w/Clamp $120.00$30.00NA w/ Xtender Power Assist; Only available w/ Mag and Lite Spoke wheelso 024A23 K0065 Black Spoke Guards $115.00024A24 K0065 Clear Spoke Guards $115.00ooSpoke GuardsTray Table024A31 E0950 Tray Table$250.00Side Guard024SG3 K0108 Plastic Regular $125.00024SG4 K0108 Plastic Kids$125.009. MISCELLANEOUSGP Series Rear STF Chart*All measurements given are an estimate and have been rounded to the nearest .5"Rear Axle Plate Hole PositionRear Axle Plate Hole PositionSHORT FrameTALL FrameStandard InvertedStandard Inverted( 9 1/4" Front / 8 1/4" Rear)( 11" Front / 10" Rear)Top Middle Bottom Top Middle BottomTop Middle Bottom Top Middle BottomWheel Rim Wheel Rim Tire22" Mag / Spoke Full Poly 14.5 15 15.5 16 16.5 17 22" Mag / Spoke Full Poly 16 16.5 17.5 17.5 18 1922" Mag / Spoke Pneum / Insert 14.5 15 16 16 17 17.5 22" Mag / Spoke Pneum / Insert 16.5 17 17.5 18 18.5 1924" Mag / Spoke Full Poly 15 15.5 16.5 16.5 17 17.5 24" Mag / Spoke Full Poly 17 17.5 18 18.5 18.5 19.524" Spoke / Spinergy Clincher 15 16 16.5 16.5 17 18 24" Spoke / Spinergy Clincher 17 17.5 18 18.5 19 19.524" Mag / Spoke / Spinergy Pneum / Insert 15.5 16 17 17 17.5 18 24" Mag / Spoke / Spinergy Pneum / Insert 17 17.5 18.5 19 19 2026" Spoke / Spinergy Clincher 16 17 17.5 17.5 18 19 26" Spoke / Spinergy Clincher 18 18.5 19 19.5 20 20.526" Spoke / Spinergy Pneumatic 16.5 17 17.5 18 18.5 19 26" Spoke / Spinergy Pneumatic 18 19 19.5 19.5 20 21STANDARD Frame( 10" Front / 9" Rear)Wheel Rim Tire22" Mag / Spoke Full Poly 15 15.5 16.5 16.5 17.5 1822" Mag / Spoke Pneum / Insert 15.5 16 17 17 17.5 1824" Mag / Spoke Full Poly 16 16.5 17 17 18 18.524" Spoke / Spinergy Clincher 16 16.5 17 17.5 18 18.524" Mag / Spoke / Spinergy Pneum / Insert 16 16.5 17.5 17.5 18 18.526" Spoke / Spinergy Clincher 17 17.5 18 18.5 19 19.526" Spoke / Spinergy Pneumatic 17 18 18.5 18.5 19.5 20Rear Axle Plate Hole Position Maximum Dump 2 3/4"Standard Inverted *** Custom Frame Height Through Configurator - REAR 6 1/2 - 13" (Max frameTop Middle Bottom Top Middle Bottom squeeze = 3 1/2") Calculate AccordinglyGP Series Front STF Chart*All measurements given are an estimate and have been rounded to the nearest .5"Fork Spacer Fork HoleSHORT Frame ( 9 1/4" Front / 8 1/4" Rear)5" Poly4" Poly6" Poly5" x 1.56" Pneu4" Lighted 5" Soft Roll 6" x 1.58" Poly 8" Pneu3"8x24 1/4 STD Bottom 15.50 16.00 16.50 17.00 17.00 x x x4 1/4 3/4 Bottom 16.50 17.00 17.00 17.50 18.00 x x x4 1/4 1 1/2 Bottom 17.00 17.50 18.00 18.50 18.50 x x x5 1/4 STD Top x x 16.50 17.00 17.00 x x x5 1/4 STD Bottom 16.50 17.00 17.5 18.00 18.00 19.00 20.5 x5 1/4 3/4 Top x x 17.50 18.00 18.00 x x x5 1/4 3/4 Bottom 17.50 18.00 18.50 18.50 19.00 19.50 20.00 x5 1/4 1 1/2 Top x x 18.00 18.50 18.50 x x x5 1/4 1 1/2 Bottom 18.00 18.50 19.00 19.50 19.50 20.50 20.50 x6 STD Top x x 17.50 18.00 18.00 18.50 19.00 x6 STD Bottom 17.50 18.00 18.50 19.00 19.00 19.50 20.00 x6 3/4 Top x x 18.00 18.50 18.50 19.50 19.50 x6 3/4 Bottom 18.00 18.50 19.00 19.50 19.50 20.50 20.50 x6 1 1/2 Top x x 19.00 19.50 19.50 20.00 20.50 x6 1 1/2 Bottom 19.00 19.50 20.00 20.50 20.50 21.00 21.50 x7 STD Top x x 18.50 19.00 19.00 19.50 20.00 x7 STD Bottom 18.50 19.00 19.50 20.00 20.00 20.50 21.00 x7 3/4 Top x x 19.00 19.50 19.50 20.50 20.50 x7 3/4 Bottom 19.00 19.50 20.00 20.50 20.50 21.50 21.50 x7 1 1/2 Top x x 20.00 20.50 20.50 21.00 21.50 x7 1 1/2 Bottom 20.00 20.50 21.00 21.00 21.50 22.00 22.50 x8x2 STD Top x x x x x x x 19.008x2 STD Bottom x x x x x x x 20.008x2 3/4 Top x x x x x x x 19.508x2 3/4 Bottom x x x x x x x 20.508x2 1 1/2 Top x x x x x x x 20.508x2 1 1/2 Bottom x x x x x x x 21.00STANDARD Frame (10" Front / 9" Rear) ADD 3/4" to each measurment aboveTALL Frame (11" Front / 10" Rear) ADD 1 3/4" to each measurment above*** Custom Frame Height through Configurator - Front 9 - 13" - Calculate Accordingly (MinimumFront STF = 15 1/2" / Max = 26")ORDERING INFORMATION PHONE: (800) 236-4215, FAX: (602) 279-0952, WEBSITE: www.southwestmedical.comPage 4