Invacare eForms

1 For additional information, visit Service: 800-333-6900 Fax: 800-678-4682 To order Literature: 800-828-6282 Invacare eFormsInvacare eForms offer new functionality! Invacare is pleased to offer you an upgraded solution to your ordering process. Our enhanced order forms allow you to fill out a form electronically, print and fax the form, save and email* it to Customer Service, or maintain the business practices that work for you today. The format has been revised to reveal a cleaner look with electronic selection and input functions. *Saving and emailing the eForms is available with Acrobat Professional softwareIf you are using Adobe Reader View and download all forms Save blank versions of the forms to your desktop Complete forms electronically Print blank or completed forms Fax completed forms to Customer Service Please note: The 'Email' button at the end of the form will not work with Adobe Reader.

2 The 'Email' button will only work while using Adobe Acrobat you are using Adobe Acrobat Professional View and download all forms Save blank AND completed versions of the forms to maintain electronic records Complete forms electronically Print blank or completed forms Fax completed forms to Customer Service Email completed forms to Customer Service by using the 'Email' button at the end of the form. For information on downloading Adobe Reader for free, or puchasing Adobe Acrobat Professional, please visit NOTE: All specifications and dimensions are approximate. For the most current pricing information, go to 1 of 8 Customer Service: 800-333-6900 Fax: 800-678-4682 To order literature: 800-828-6282 price list and Order Phone #Company NameAddress City Zip Code Account # # State CountryContact Name CommentsOrderQuoteTRANSACTION TYPE: Invacare Solara 3G - Adult Tilt-in-Space Wheelchair Special NoteHCPCS codes are not intended to be, nor should be considered billing or legal advice.

3 Providers are responsible for determining the appropriate billing codes when submitting claims to the Medicare Program and should consult an attorney or other advisor to discuss specific situations in further SELECTIONSFRAME TYPEE1161 SOLARA3G Solara 3G Tilt-in-Space wheelchair .. $2, seating system must be purchased. No seating system is provided. 300 lb standard weight for additional information when configuring this No. 08-030 HDPG Heavy Duty Package (400 lbs. Weight Capacity) $ PACKAGESK0108 Reinforced axles and crossbraces. Weight limit of 400 TRAY SELECTIONT ransport Tie Down TRRO includes four factory-installed transport brackets and wheelchair anchored pelvic belt. TRRO has been crash-tested in accordance with ANSI/RESNA WC Vol 1.

4 Section 19 Frontal Impact Test requirements for wheelchairs with a 168 lbs. crash dummy, which corresponds to a person with a weight of 114 lbs. to 209 lbs. TRBKTS includes four factory-installed wheelchair transport brackets. TRBKTS has not been crashtested in accordance with WC19. Use these transport brackets only to secure an unoccupied wheelchair during transport. As of this date, the Department of Transportation has not approved any tie-down systems for transportation of a user while in a wheelchair, in a moving vehicle of any type. It is Invacare s position that users of wheelchairs should be transferred into appropriate seating in vehicles for transportation and use be made of the restraints made available by the auto industry.

5 Invacare cannot and does not recommend any wheelchair transportation systems. TRANSPORT TIE DOWNTRRO Transport Ready Option .. $ Transport Brackets .. $ available with AVENT, BACKVENT, P750, available with W23, W24, HDPG, AVENT, BACKVENT, LOSHEAR, LOSHEARWO, P750, 2218, OFFMNT, BILAT, available as a service part kit for existing models. VENT TRAY OPTIONE1029 AVENT Ventilator Tray (each) .. $ Ventilator Battery Box (each) .. $ Laptop Vent Tray .. $1, available with available with HDPG, LOSHEAR, with 15" wide frame and with 16" wide frame and above and 18" Seat-to-Floor Height and above. TLC Tilt Lock Stops (pair) .. $ TLL Tilt Lock Levers .. No Charge FRLT Cable-Free Foot Release-Left Mount.

6 No Charge FRRT Cable-Free Foot Release-Right Mount .. No ChargeTHR Traditional Hand Release .. StandardTILTING OPTIONSA dditional pair of tilt lock stops, one pair comes standard with 12" 16" Seat Width Range .. No ChargeSWR1418 14" 18" Seat Width Range .. No ChargeSWR1620 16" 20" Seat Width Range .. No ChargeSWR1822 18" 22" Seat Width Range .. No ChargeSWR2024 20" 24" Seat Width Range .. No ChargeSEAT WIDTH RANGENot available with SELECTIONSSUSPENSION SELECTION SUSPENSIONDROCK DeGage Dynamic Rocker Back .. $ Frog Legs Suspension Forks .. $ Suspension Package .. $ available with HDPG, TRRO, LOSHWEAR, LOSHEARWO, RCANE, FLDBACK. See for more details. Not available with HDPG, TRRO.

7 See chart page available with HDPG, TRRO, LOSHEAR, LOSHEARWO, RCANE, FLDBACK. Includes DROCK and Sep 14, 2012 NOTE: All specifications and dimensions are approximate. For the most current pricing information, go to 2 of 8 Invacare Solara 3G - Adult Tilt-in-Space Wheelchair Form No. 08-030 STF125 Seat-To-Floor 12 1/2" (10 1/2" w/DPSEAT) .. No ChargeSTF13 Seat-To-Floor 13" (11" w/DPSEAT) .. No ChargeSTF135 Seat-To-Floor 13 1/2" (11 1/2" w/DPSEAT) .. No ChargeSTF14 Seat-To-Floor 14" (12" w/DPSEAT) .. No ChargeSTF145 Seat-To-Floor 14 1/2" (12 1/2" w/DPSEAT) .. No ChargeSTF15 Seat-To-Floor 15" (13" w/DPSEAT) .. No ChargeSTF155 Seat-To-Floor 15 1/2" (13 1/2" w/DPSEAT) .. No ChargeSTF16 Seat-To-Floor 16" (14" w/DPSEAT).

8 No ChargeSTF165 Seat-To-Floor 16 1/2" (14 1/2" w/DPSEAT) .. No ChargeSTF17 Seat-To-Floor 17" (15" w/DPSEAT) .. No ChargeSTF175 Seat-To-Floor 17 1/2" (15 1/2" w/DPSEAT) .. No ChargeSTF18 Seat-To-Floor 18" (16" w/DPSEAT) .. No ChargeSTF185 Seat-To-Floor 18 1/2" (16 1/2" w/DPSEAT) .. No ChargeSTF19 Seat-To-Floor 19" (17" w/DPSEAT) .. No ChargeSEAT-TO-FLOOR HEIGHTSDR1216 12" 16" Seat Depth Range .. No ChargeSDR1519 15" 19" Seat Depth Range .. No ChargeSDR1822 18" 22" Seat Depth Range .. No ChargeSEAT DEPTH RANGETilt Assist feature not available on this frame. SEAT DEPTHD12 12" Seat Depth .. No ChargeD13 13" Seat Depth .. No ChargeD14 14" Seat Depth .. No ChargeD15 15" Seat Depth.

9 No ChargeD16 16" Seat Depth .. No ChargeD17 17" Seat Depth .. No ChargeD18 18" Seat Depth .. No ChargeD19 19" Seat Depth .. No ChargeD20 20" Seat Depth .. $ 21" Seat Depth .. $ 22" Seat Depth .. $ FINISH4 SPLT 4" x 1" Composite Urethane Light Up .. No Charge4 ALUM2 4" x " Aluminum Soft Roll .. $ 5" x 1 Composite Urethane Light Up .. No Charge51DC 5" x 1" Urethane Casters .. No Charge5 ALUM2 5" x " Aluminum Soft Roll .. $ 6" x 1" Urethane Caster .. No Charge1259 6" x 2" Semi-Pneumatic Casters .. $ 6" x " Aluminum Soft Roll .. $ 8" x 1" Urethane Casters .. No Charge815DC 8" x " Urethane Caster .. No ChargeCASTER OPTIONS (PAIR)Not available with available with available with available with available with 12" Composite Wheels.

10 No Charge16 COM 16" Composite Wheels .. No Charge18 COM 18" Composite Wheels .. No Charge20 COM 20" Composite Wheels .. No Charge22 COM 22" Composite Wheels .. No Charge24 COM 24" Composite Wheels .. No ChargeWHEEL OPTIONS (PAIR)Not available with urethane available with urethane available with aluminum available with urethane available with aluminum Quick Release Axles .. No ChargePAXLE Permanent Axles ..StandardAXLE TYPE (PAIR)CASTER, WHEEL AND TIRE SELECTIONS Touch Up Paint .. $ Wet Black .. No Charge29P White No Charge60P Silver Metallic .. No Charge115P Black Prism .. No Charge105P Midnight Blue .. No Charge30P Sunny Yellow .. No Charge61P Electric Red .. No Charge119P Bubblegum Pink.