Invacare eForms Storm Series... · For additional information, visit . Customer Service:...

For additional information, visit www.invacare.com/eForms www.invacare.comCustomer Service: 800-333-6900 Fax: 800-678-4682 To order Literature: 800-828-6282

Invacare eForms

Invacare 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 software

If 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. The 'Email' button will only work while using Adobe Acrobat Professional.

If 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 www.adobe.com.

NOTE: All specifications and dimensions are approximate. For the most current pricing information, go to www.invacare.com/homecare.

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Customer Service: 800-333-6900 Fax: 800-678-4682 To order literature: 800-828-6282

Price List and Order Form www.invacare.com

Date

Phone #Company Name

Address City Zip Code

Account # P.O. #

State Country

Contact Name Comments

Order Quote

TRANSACTION TYPE:

Special NoteHCPCS codes are not intended to be, nor should be considered billing or legal advice. 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 detail.

Form No. 07-031Revised December 1, 2016

FRAME SELECTION

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TRBKTS Wheelchair Transport Brackets .................................. $250.00

TRANSPORT TIE-DOWNMust select Group 24 battery boxes for TRBKTS.

TRANSPORT TIE-DOWN*

TRBKTS includes four factory-installed wheelchair transport brackets. TRBKTS has not been crash-tested 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. Invacare cannot and does not recommend any wheelchair transportation systems. * Transport Tie-Down option is not retrofittable to existing models and is not field serviceable.

Invacare® Storm Series® Storm Torque™ 3 and Torque™ SP Power Wheelchair

CHAIR TYPE3GTQ3 Torque 3 Base and Seat with MK6i™ ............. $5,970.00 K0848

Torque 3 comes standard with 300 lb. user weight capacity, 5.8 mph top speed, 4-pole motor package, MK6i SPJ™+ joystick, MK690 Controller

3GTQSP Torque SP Base and Seat with MK6i ............. $6,850.00 K0868Torque SP comes standard with 300 lb. user weight capacity, 6 1/2 mph maximum speed, performance 4-pole motor package, SPJ+ joystick and MK690 Controller

3GSEAT Seat Only ..................................................................... $755.00When ordering a replacement seat and changing depth to 20" or deeper, order new arms.

Group 4 - K0868 Basic Package3G Torque SP with MK6i300 lbs. Weight Capacity

1431-3 14" x 3" Tires with Foam Filled Inserts No ChargePerformance 4 Pole Motors Standard

1228-3 8" x 2 1/4" Semi Pneumatic Casters Standard29F Desk Length Adjustable Height Arms $230.00

MK690 Controller Standard70NHD 70° Swingaway Footrests Standard8 Amp Off Board Battery Charger Standard

1515 Push Button Style Seat Positioning Strap Standard

Group 3 - K0848 Basic Package3G Torque 3 with MK6i300 lbs. Weight Capacity

1431-3 14" x 3" Tires with Foam Filled Inserts No Charge4 Pole Motors Standard

1228-3 8" x 2 1/4" Semi Pneumatic Casters Standard29F Desk Length Adjustable Height Arm $230.00

70NHD 70° Swingaway Footrests Standard8 Amp Off Board Battery Charger Standard

1515 Push Button Style Seat Positioning Strap Standard

SFS Short Base ................................................................. StandardLFS Long Base .............................................................. No Charge

FRAME TYPE



SEAT SELECTION BACK SELECTION

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1620W 16" to 20" Seat Width Range ................................. No Charge2024W 20" to 22" Seat Width Range ................................. No Charge

ADJUSTABLE SEAT WIDTH RANGE

W16 16'' Wide ................................................................. No ChargeW17 17'' Wide ................................................................. No ChargeW18 18'' Wide ................................................................. No ChargeW19 19'' Wide ................................................................. No ChargeW20 20'' Wide ................................................................. No ChargeW21 21'' Wide ...................................................................... $329.00W22 22'' Wide ...................................................................... $329.00

FRAME WIDTHContoura seating available in even widths 16"-22".

SEAT SELECTIONADJASBA Adj Rehab Seat with Adj Seat Tilt and Back Angle ............... No Charge

CTB Contoura Seating................................................. $605.00CURV Curved ........................................................... No Charge

E2620

Does not include seat cushion, need to order separately.

1619D 16" to 19" Seat Depth Range ................................. No Charge1922D 19" to 22" Seat Depth Range (Long Base)............. No Charge

ADJUSTABLE SEAT DEPTH RANGE

D16 16'' Seat Depth (Short Base) ....................................No ChargeD17 17'' Seat Depth (Short Base) ....................................No ChargeD18 18'' Seat Depth (Short Base) ....................................No ChargeD19 19'' Seat Depth (Long Base) ....................................No ChargeD20 20'' Seat Depth (Long Base) ....................................No ChargeD21 21'' Seat Depth (Long Base) ........................................ $529.00D22 22'' Seat Depth (Long Base) ........................................ $529.00

SEAT DEPTH SETTING

SECT Sectional Rear Uprights ......................................... No ChargeL8661 Omit Rear Uprights ............................................. Less $20.00

ADJASBA BACK TYPE

BH16 16'' Back Height ..................................................... No ChargeBH17 17'' Back Height ..................................................... No ChargeBH18 18'' Back Height ..................................................... No ChargeBH19 19'' Back Height ..................................................... No ChargeBH20 20'' Back Height ..................................................... No ChargeBH21 21'' Back Height ..................................................... No ChargeBH22 22'' Back Height ..................................................... No ChargeBH23 23'' Back Height ..................................................... No ChargeBH24 24'' Back Height ..................................................... No Charge

BACK HEIGHT ADJASBA

90BA 90° .......................................................................... No Charge95BA 95° .......................................................................... No Charge 100BA 100° ........................................................................ No Charge

85BA 85° .......................................................................... No Charge

105BA 105° ........................................................................ No Charge

SEAT BACK ANGLE DEGREE

L8601 Omit Back Upholstery ........................................... No ChargeRBP Reinforced Back Upholstery .................................. No Charge

BACK ACCESSORIES

ARM SELECTION


TSBH22 22" Back Height ..................................................... No ChargeTSBH25 25" Back Height ..................................................... No ChargeTSBH28 28" Back Height ..................................................... No Charge

CONTOURA BACK HEIGHT

ARM TYPE

19F Full Length Adj Hgt. Conv. Flip Up .................. $230.0029F Desk Length Adj Hgt. Conv. Flip Up ................ $230.00L8401 Omit Arms .............................................................. No Charge

E0973E0973

All arms are flip up and detachable.

ARM TYPE RIGHT (each)R19F Full Length Adj Hgt. Conv. Flip Up .................. $115.00R29F Desk Length Adj Hgt. Conv. Flip Up ................ $115.00

E0973

E0973

ARM TYPE LEFT (each)L19F Full Length Adj Hgt. Conv. Flip Up .................. $115.00L29F Desk Length Adj Hgt. Conv. Flip Up ................ $115.00

E0973

E0973

LOW Seat-To-Floor - Low 17.25'' .................................. No ChargeMED Seat-To-Floor - Med 19.50" .................................. No ChargeTALL Seat-To-Floor - Tall 20.75'' ................................... No Charge

SEAT-TO-FLOOR HEIGHTListed values are for O degree Seat Angle and w/o TRBKTS. Please see below for additional information. (Values with an "F" represent factory settings,which are the lowest possible STF)

ELECTRONICS



SIP-N-PUFF KITE2326PKG32666 Therafin Sip-N-Puff Breath Tube Kit ............... $380.00

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MK6i ELECTRONIC CONTROLLERSMK690 90 Amp Controller ............................................ StandardGTRAC G-Trac™ Module ................................................ $995.00 K0108

G-Trac provides improved Tracking Capabilities and Enhanced Traction. Does not require special motors. Not available with SPJ+ joysticks or MK6TT.

FOR INFORMATION ON ASL ELECTRONICS PLEASE CALL 1-800-626-8698 OR VISIT WWW.ASL-INC.COM

ALTERNATIVE PROPORTIONAL CONTROL SYSTEMS1558MM6 Compact Joystick with Display ...................... $1,130.00 E2373

ALTERNATIVE DIGITAL CONTROL SYSTEMSE2325SNPM6 Sip-N-Puff Digital Interface Box .................... $1,500.00

Must also use either a Multiple Drive Joystick or MK6 Display.

1558M6 Compact Joystick - Less Std Mount .......................... $770.00PACM6 Prop Attendant Control with quick release mount .... $850.00

ADDITIONAL CONTROL CHOICES

QLAM6 Quad Link Retract. Joystick Mnt CMPJ+ ........ $279.00

JOYSTICK MOUNTING HARDWAREE1028

E1028QLA Quad Link Retract. Joystick Mnt SPJ+ ............ $279.00

E1028ARM250 Stealth Height Adjustable Joystick Mount ....... $210.00LEFT Left Handed Mounted Joystick .................... No Charge

QLA and QLAM6 include ARM250 standard.

QLA and QLAM6 include ARM250 standard.

ELECTRONIC ACCESSORIES1813M6 MK6i Programmer with Pro Memory Card .............. $475.001813SD Pro Memory Card (USB Ready) ................................. $90.00A24VPS 24V MK6 Auxiliary Power Source .......................... $200.00AUX12M6 Auxiliary Module for outputs 1 and 2 ....................... $795.00AUX34M6 Auxiliary Module for outputs 3 and 4 ....................... $795.00MPY Monoport "Y" Cable for CMPJ+ or Display ............... $15.002PB Dual Push Button ...................................................... $147.00

PBMT Push Button Mounting Kit ......................................... $252.00

Option to replace Mono Port "Y"cable when requiring two switch functions of the mode switch port on expandable controller systems. Not compatible with SPJ+ Joystick options.

EGSBLK Egg Switch-Black ...................................................... $156.00ASL611 Adjustable Switch Mounting Bracket ........................ $252.00

ASL OPTIONAL ACCESSORIES

FRAME AND UPHOLSTERY COLOR

U240 Black Nylon Upholstery ............................................ Standard

UPHOLSTERY TYPE

FRAME FINISH

24P Wet Black ............................................................... No Charge60P Silver Metallic ........................................................ No Charge105P Midnight Blue ........................................................ No Charge115P Black Prism ............................................................ No Charge

30P Sunny Yellow ......................................................... No Charge61P Electric Red ............................................................ No Charge119P Bubblegum Pink ..................................................... No Charge120P Grape Madness ....................................................... No Charge

62P Electric Blue ........................................................... No Charge127P Grasshopper Green ................................................. No Charge116P Sunkissed Orange ................................................... No Charge117P Tangerine Red ........................................................ No Charge29P White Snow ............................................................ No Charge

CONTEMPORARY

TOO HOT

WAY COOL

CASTER AND WHEEL SELECTIONS

1228-3 8'' x 2 1/4'' Semi-Pneu Casters Lt Grey ..................... Standard1251-3 8'' x 2'' Pneumatic Casters ...................................... No Charge

CASTER OPTIONS

1430-3 14'' x 3'' Pneumatic Tires .......................................... Standard1431-3 14'' x 3'' Tires w/Foam Filled Inserts .................... No Charge

WHEEL OPTION

RWF2 Rear Wheel Forward 2'' .......................................... No ChargeRWF1 Rear Wheel Forward 1'' ...........................................No ChargeRWS Rear Wheel Standard ................................................. Standard

REAR WHEEL LOCATIONThis location changes the center of gravity and performance. Forward wheel position will make turning and climbing easier, but more prone to "wheely".


SPJPLUS SPJ+ Single Drive Joystick ....................................... Standard

STANDARD DRIVER CONTROL

CASTER SUSPENSION9213-8 Shock Fork For 8'' Casters ................................. $119.00 E1016

Not available with Short Base TBKTS.

FDR Fender ......................................................................... $320.00

FENDER OPTION

CMPJM6U MPJ™+ Multiple Drive Joystick with Color Display $750.00ASLRDYM6 MK6i Display Only (No Driver Control) .......... $750.00

EXPANDABLE CONTROLLER SYSTEMPWH Harness req. for Expandable Electronics ........... $350.00 E2313

E2377

E2377

Required to interface joystick or MK6i display with expandable controllers.

Display only, No Driver Control. Allows choice from order form.

POSITIONING STRAPS

BATTERY SELECTION

FRONT RIGGING OPTIONS

FRONT RIGGING



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1515 Push Button Style Seat Positioning Strap ................. Standard

SEAT POSITIONING STRAPS

CHEST POSITIONING STRAPS7321BK Hook and Loop Chest Positioning Strap ............ $100.00 E0960

MISCELLANEOUS ACCESSORIES1303 Wheel Locks ....................................................... $45.00

E10169205-3 Suspension Shocks ............................................ $400.00

GP24 Group 24 Battery Boxes ......................................... No Charge

BATTERY BOXES

Required for transport tie down option.

24BATTERY 24 Gel Battery (On Chair) ................................. $410.00

INSTALLATION OF BATTERIES

E2363

Batteries will be installed by Invacare Corporation. Chair will be shipped complete with batteries.

BATTERY CHARGER OPTION110CHARGER 110 Volt Battery Charger ....................................... No ChargeL8900 Omit Battery Charger ............................................ Less $80.00

ASB Center Pivot Style Bracket ..................................... No ChargeNHB No Hanger Bracket ................................................ No Charge

HANGER BRACKET TYPE

CENTER PIVOT70NHD 70° Swingaway Footrests 13 1/4" - 17" ............ Standard70STAPER 70° Tapered Footrests 13"-17" ...................... No ChargeAT5044 Elevating Legrests .............................................. $255.00 E0990

FOOTPLATE OPTIONS1651 Flip-Up Composite Footplates ...................... No Charge1350 Extra Large Aluminum Footplates ................ No ChargeAT5543 Adjustable Angle Flip Up Footplates ................ $165.00 K0040

FOOTREST/LEGREST ACCESSORIES1337 Calf Strap ............................................................. $27.00 K0038

HLOOP Heel Loops (pair) ................................................. $45.00 E0951

IMPACTG Impact Guards ...................................................... $51.00LPT2 Longer Pivot Slide Tube For 1350 ....................... $83.00ALPT Longer Pivot And Slide Tube .............................. $84.00ALPT3 3'' Extension For 90° Footrest .............................. $31.00ALPT4 Longer Pivot And Slide Tube 4'' .......................... $84.00


ADDUCTORSADD Adductors, small ............................................... $200.00 E0960

ADD-HW Hardware for small Adductorts ............ $400.00 E0960

Chair Features and Options • Independent rear wheel suspension with new rubber element design • 5.8 mph standard speed range • Programmable performance to meet individuals needs • 17.75'' Seat-to-Floor Standard, 20'' and 21.25'' Optional • Seat location system allows for balanced weight distribution • Continuous tilt seat 0° - 10° • Dynamic anti tippers • Rigid seat pan • Convenient rear battery access • 22NF batteries (standard) In a single 22NF battery box Single battery connector • Arms are flip back/removable • Adjustable depth rigging attachment 2'' (1'' increments) • Automatic dual mode battery charger (Lester Brand) • Compact size: 24.75'' overall base width with 14'' x 3'' wheels • Weight limit <300 lbs.

Weight Limit 300 Invacare recommends all wheelchairs be fitted and programmed to the consumer under the guidance of a healthcare professional,

knowledgeable of the particular limitations of the product.

Note: All weight limits are inclusive of add-on equipment and seat systems.

Seating and Positioning For your seating needs, please refer to the following rehab seating and

positioning products: Price List Form No. 07-027

Torque 3 Specifications

Overall Width* with 14" x 3" wheel 25"

with 14" x 4" wheel 27 1/2"

Overall Length** Short Base 28 1/2"

Long Base 31 1/2"

Seat-to-Floor*** Low, Standard 17 1/4"

Medium, Optional 19 1/2"

Tall, Optional 20 3/4"

Battery 24 deep cycle; gel/sealed (not supplied)

Shipping Weight 266 lb. (18" X 18" seat w/Group 24 batteries) *Measurement based on wheel base. Seat width is width picked plus 7.5" for the armrest and joystick. **Measured from headtube to anti-tipper. ***Based on 0 degree tilt and 16" seat depth; add 1/4" for additional 2" of seat depth. Note: all specifications and dimensions are approximate.



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Short Frame (16-19" Seat Depth) Long Frame (19-22" Seat Depth)Low Medium Tall Low Medium Tall

Non - Powered Seating

0 Degree Seat Angle w/ TRBKTS

17.5 19.75F 21F 17.75 20F 21.25F

w/o TRBKTS 17.25F 19.5F 20.75F 17.5F 19.75F 21F


Footrest Extension Range

AT5043 AT5543 1651

70NHD N/A 10 3/4" - 15 3/4" 11 3/4" - 17"

70STAPER N/A 12 1/2" - 16 1/2" 13 1/4" - 17 1/4"

Measured from Seat Pan to Back of Footplate

Memory Card - BASIC • Standard with ALL Expandable Control Systems (CMPJ+, MK6i Display). • Used to back up / restore programmed settings for only one chair. • May be given to user or kept with provider's files for safe keeping. • Does not contain advanced diagnostics / help screens / file structure. • Not compatible with SPJ+ Joysticks.

Memory Card - PROFESSIONAL • Standard with ALL MK6i Programmers. • Available also with USB Card Reader on Order Form. • Contains advanced diagnostics, help screens, software upgrades, file storage / retrieval • Used to back up multiple chairs and programming settings. • Intended for use by qualified providers only. • Not compatible with SPJ+ Joysticks.


Comments


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Invacare Corporation www.invacare.com USA One Invacare Way Elyria, OH USA 44035-4190 800-333-6900

©2016 Invacare Corporation All rights reserved. Trademarks are identified by the symbols ™ and ®. All trademarks are owned by or licensed to Invacare Corporation unless otherwise noted. Monroe is a registered trademark of Tenneco Automotive, Inc. Therafin is a registered trademark of W/R Medical Electronics Co. Products designated by ASL are Manufactured by Adaptive Switch Labs, Inc. Specifications and prices are subject to change without notification.


Contoura Seat Sizes

D16 D17 D18 D19 D20 D21 D22

W16 * * * * * * *

W18 * * * * * * *

W20 * * * * * * *

W22 * * * * * * *

W24 * * * * * * *

*Not available with Contoura Seat Cushion

Back Heights 22", 25" or 28"

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