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 5 NOTE: All specifications and dimensions are approximate. For the most current pricing information, go to Self Propelling Tilt .. $2, FRAME TYPEE1161 SEAT PANFLSEAT Flush Mounted Seat Pan.

3 $ systems must be purchased for use with this to Floor HeightCaster Mounting PositionWheel SizeWheel Mounting Position14 1/2"Top20"Top15 1/2"Middle22"Top16 1/2"Bottom24"Top16 1/2"Bottom20"BottomSeat-to-Floor Matrix 6" Casters13 1/2" seat-to-floor height available with 18" composite wheel and 5" caster. Use specials number SM-060929111549 ARM TYPE (PAIR)E0973 ADJDESK Conv Adjust. Ht., Desk Lgth. Arms .. $ Conv Adjust. Ht., Full Lgth. Arms .. $ T - Arm Adj Height, Desk Length .. $ T - Arm Adj Height, Full Length .. $ Conv Fixed Ht., Desk Lgth. Arms .. No ChargeFXFULL Conv Fixed Ht., Full Lgth. Arms .. No ChargeE0973E0973E0973 Only available with available with Compass SPT Form No. 03-069 SEAT WIDTH SETTINGW14 14'' Seat Width .. No ChargeW15 15'' Seat Width .. No Charge W16 16'' Seat Width .. No Charge W17 17'' Seat Width.

4 No ChargeW18 18'' Seat Width .. No ChargeW19 19'' Seat Width .. No ChargeW20 20'' Seat Width .. $ 21'' Seat Width .. $ 22'' Seat Width .. $ HEIGHT Seat-To-Floor .. No Charge (MUST WRITE IN SEAT TO FLOOR TO COMPLETE ORDER) Seat to Floor HeightCaster Mounting PositionWheel SizeWheel Mounting Position15 1/2"Top22"Top16 1/2"Middle20"Bottom16 1/2"Middle24"Top17 1/2"Bottom22"BottomSeat-to-Floor Matrix 6" x 2" CastersSeat to Floor HeightCaster Mounting PositionWheel SizeWheel Mounting Position16 1/2"Top20"Bottom16 1/2"Top24"Top17 1/2"Middle22"Bottom18 1/2"Bottom24"BottomSeat-to-Floor Matrix 8" CastersL8-12 Low Range 8'' - 12'' (T - Arm Height) .. No ChargeH10-16 High Range 10'' - 16'' (T - Arm Height) .. No ChargeClearT-ARM HEIGHTARM SELECTIONC ustomer 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:Special NoteHCPCS codes are not intended to be, nor should be considered billing or legal advice.

5 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 DEPTH SETTINGSDS15 15'' Seat Depth .. No Charge SDS16 16'' Seat Depth .. No ChargeSDS17 17'' Seat Depth .. No ChargeSDS18 18'' Seat Depth .. No ChargeSDS19 19'' Seat Depth .. No ChargeSDS20 20'' Seat Depth .. $ 21'' Seat Depth .. $ 22'' Seat Depth .. $ Oct 25, 2012 NOTE: All specifications and dimensions are approximate. For the most current pricing information, go to Oct 25, 2012 CASTER OPTIONS (PAIR)61DC 6'' x 1" Urethane Casters .. No Charge81DC 8'' x 1'' Urethane Casters .. No Charge1292 8'' x 1 1/4'' Pneumatic Casters .. $ 8'' x '' Urethane Casters ..No Charge1259 6'' x 2'' Semi Pneumatic Casters .. $ 8'' x 1'' Solid Rubber Casters.

6 No Charge1492 Flat Free Inserts for 8'' x 1 1/4'' Pneu Casters .. $ 1/2" seat-to-floor height available with 18" composite wheel and 5" caster. Use Special # OPTIONS (PAIR)PNEU Pneumatic Tires .. $ Flat Free Inserts .. $ Urethane (Treaded) .. No ChargeKIKB KIK Black Tires .. $ available with with 24 COM7 Wheel Aluminum Handrims .. No ChargeCHDRM Chrome Plated Handrims .. No Charge A1512K Black Plastic Coated Handrims .. $ Plastic Coated with 8 Oblique Projections .. $ Plastic Coat with 8 Vertical Projections .. $ Plastic Coat with 12 Vertical Projections .. $ Natural Fit Handrims Standard Grip .. $ Natural Fit Handrims Super Grip .. $ Omit Handrims .. Less $ OPTIONS (PAIR)Available only on 24 COM7 Available only on 24 COM7 Invacare Compass SPT FWDFS Front Wheel Configuration .. No ChargeRWDFS Rear Wheel Configuration.

7 No ChargeFRONT WHEEL CONFIGURATIONS20 COM 20'' Composite Wheels .. No Charge22 COM 22'' Composite Wheels .. No Charge24 COM7 24'' Composite 7 Spoke Wheels .. No ChargeWHEEL OPTIONS (PAIR)A1577 Quick Release Axles .. No ChargePAXLE Permanent Axles .. No ChangeAXLE TYPE (PAIR)FRAME FINISHPOSITIONING STRAPSCASTER AND WHEEL SELECTIONPOSITIONING STRAPSE09781311BK Airline Style Buckle Seat Pos Strap (ea) .. $ Push Button Buckle Seat Pos Strap (ea) .. $ Hook and Loop Seat Pos Strap (ea) .. $ Airline Style Chest Pos Strap (ea) .. $ Push Button Chest Pos Strap (ea) .. $ Hook and Loop Chest Pos Strap (ea) .. $ Adjustable Height Back Canes (17'' - 20'') .. No ChargeBH20 20'' Back Height .. No ChargeBH24 24'' Back Height .. No ChargeBACK HEIGHTMust choose the AASH or AASHIN when ordering the ABH1720. The 1483 Non-Adjustable Rigidizing Handle bar is not available with No.

8 03-06990BA 90 Back Angle Setting .. No Charge100BA 100 Back Angle Setting .. No Charge110BA 110 Back Angle Setting .. No Charge120BA 120 Back Angle Setting .. No ChargeBACK ANGLE ADJUSTMENTBACK SELECTIONBKUP With Back Upholstery .. No ChargeClearBACK UPHOLSTERY 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 .. No Charge120P Grape Madness .. No Charge62P Electric Blue .. No Charge127P Grasshopper Green .. No Charge116P Sunkissed Orange .. No Charge117P Tangerine Red .. No ChargeFRAME COLORST ouch Up ColorTouch up paint is not available in all frame colors are available through our specials department. C-070109030544 ACCESSORIESSP-01 Seat Pouch .. $ ACCESSORIESMISCELLANEOUS ACCESSORIESE0961A1576 Wheel Lock Extensions (6'') (pair).

9 $ 3/4'' - 1'' Clamp Assembly .. $ Crutch and Cane Holder .. $ Tire Pump .. $ Foot Operated Tilt Assist .. $ Tilt Trigger Lock Out Levers .. No ChargeClearE2207 Not available with 14'' Cane Mount Hublock (attendant) .. $ Seat Rail Mount Hublock .. $ LOCKSUSEHUB not available with FWDFS Front Wheel Drive Back Pack .. $ Non Adjustable Rigidizing Handle Bar .. $ Adj. Angle Stroller Handles (Outside Mount) .. $ Adj. Angle Stroller Handles (Inside Mount) .. $ ACCESSORIESAASH release buttons are mounted on the outside and AASIN release buttons are mounted on the release buttons are mounted on the outside and AASIN release buttons are mounted on the RIGGING (PAIR)PHW93 Swingaway Footrest 13 1/2'' - 19''.. No ChargeSWING1319 60 Swingaway Footrests .. No Charge70 NTAPER 70 Swingaway Footrests ..No Charge70 MFX 70 Swingaway Footrests MFX.

10 No Charge90 SWING 90 Swingaway Footrests .. No Charge PH904A Swingaway Elevating Legrest 16" - 19 3/4'' .. $ Elevating Legrests .. $ Smartleg Articulating Legrest 17 1/4'' - 21 1/2'' $ Center Pivot Articulating Legrests .. $ 70 Lift off Non - Taper Footrests .. $ 90 Lift off MFX Footrests .. $ Pivot Front Rigging only available with RWDFSNot available with 15", 16" or 17" seat available with 1651 flip-up composite AND LEGREST ACCESSORIESK0038A1337 Calf Strap (each) .. $ ChairArmor Black Neoprene Frame Protectors .. $ ChairArmor Silver Neoprene Frame Protectors .. $ ChairArmor Red Neoprene Frame Protectors .. $ ChairArmor Blue Neoprene Frame Protectors .. $ Longer Pivot And Slide Tubes (pair) .. No Charge9342 "H" Strap (each) .. $ is available on PHW93 and 70 NTAPER on 16" - 22" chairs using composite or adjustable angle footplates.