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Account #:_____________________________________ Purchase Order #:________________________ Date:______________________ Contact:______________________________________________ Mark For:_________________________________________________ Bill To: Ship To: Address: Address: City/State/Zip: Phone: Fax: City/State/Zip: Email: Phone: Safari Tilt Standard Features: *** Measurements: ● 5° to 45° of Adjustable Tilt ● 2-Point Positioning Belt ● Silver Powder Coated Frame ● Heavy-Duty Back Upholstery *** Seat Depth: _____________* ● 7.5 x 2" Front, 11.5 x 2.5" Rear Solid Tire (SFT12/14/16) ● One Piece, Non-Folding/Non-Elevating Footplate ● 6" Front, 11" Rear Solid Tires (SFT18) ● Support Cushion with Solid Seat Insert *** Lower Leg Drop: _________* ● Quick Release Rear Wheels (SFT12/14/16) ● Made in the USA ● Wheel Locks *** *if this field is left blank, *** defaults will be set Standard Models: Price Safari SFT12 - 900493 $2,365 Safari SFT14 - 901104 $2,365 Safari SFT16 - 900526 $2,365 Safari SFT18 - 902432 $2,365 Upholstery Colors Price SFT12 SFT14 SFT16 SFT18 Royal Blue $0 903850 903850 903850 903850 Forest Green $0 903857 903857 903857 903857 Cherry Red $0 903855 903855 903855 903855 Sassy Purple $0 903851 903851 903851 903851 Princess Pink $0 903759 903759 903759 903759 Panther Black $0 903854 903854 903854 903854 Chocolate Brown $0 904189 904189 904189 904189 Aqua Blue $0 904753 904753 904753 904753 Apple Green $0 904754 904754 904754 904754 Transit Required Items Price HCPCS SFT12 SFT14 SFT16 SFT18 Transit Option (Manufacturer Installation Required) $200 900494 901141 900527 902435 Headrest Extension $130 E0966 900712 901168 901310 902471 H-Harness with Padded Covers $143 E0960 903988 903988 903988 903988 3-Pt Positioning Belt $49 E0978 904017 904017 904017 904017 Elevating Legrests with Swing-Away Footplates (pair) $270 E0990 900698 901117 901299 902460 Foot Positioners - Select Size Below: Foot Positioners - Small 7" - 10" (pair) $156 903415 903415 903415 903415 Foot Positioners - Medium 8" - 11" (pair) $156 903416 903416 903416 903416 Foot Positioners - Large 9" - 12" (pair) $156 903417 903417 903417 903417 Transit Options Price HCPCS SFT12 SFT14 SFT16 SFT18 Q'Straint Transit Lap Belt $90 E0978 903095 903095 903095 903095 Sure-Lok Transit Lap Belt $90 E0978 903233 903233 903233 903233 Upper Extremity Support Surface (Foam Tray) Small^ $151 E0950 903669 N/A N/A N/A Upper Extremity Support Surface (Foam Tray) Medium^ $151 E0950 N/A 903670 903670 N/A Upper Extremity Support Surface (Foam Tray) Large^ $151 E0950 N/A N/A N/A 903671 ^ Crash tested Foam Tray with vinyl cover. Flip-Up Armrests required. Pelvic Positioning Price HCPCS SFT12 SFT14 SFT16 SFT18 3-Pt Positioning Belt $49 E0978 904017 904017 904017 904017 Position Cushion - Medial Thigh Support/Anti Thrust * $347 E2607 903588 903589 903590 903591 Align Cushion - Lateral Pelvis/Lateral Thigh Support * $347 E2607 903592 903593 903594 903595 Incontinence Cushion Liner (Cushion and Solid Seat req) $72 E2619 902324 902324 902324 902324 Solid Seat Insert (Required with Cushion) $119 E0992 904029 904029 904029 904029 * Solid Seat Insert required with any Cushion. Foot & Leg Positioning Price HCPCS SFT12 SFT14 SFT16 SFT18 Foot Positioners - Small 7" - 10" (pair) ^ $156 903415 903415 903415 903415 Foot Positioners - Medium 8" - 11" (pair) ^ $156 903416 903416 903416 903416 Foot Positioners - Large 9" - 12" (pair) ^ $156 903417 903417 903417 903417 Elevating Legrests w/ Swing-Away Footplates (pair) $270 E0990 900698 901117 901299 902460 Legrest Extension - 3" * ^ $55 N/A 901325 901324 902478 Angle Adj. Footplates - Std Size (pair) ^ $179 K0040 903270 903270 N/A N/A Angle Adj. Footplates - Adult Size (pair) ^ $179 K0040 N/A N/A 903271 903271 Footplate Securement Strap $30 903584 903584 903584 903584 Medial Thigh Support (Abductor) $162 E0957 900708 901113 901297 902458 Lateral Thigh Support (Adductor) $162 E0956 900709 901145 901298 902459 Calf Panel $61 E0995 904580 904580 904580 904580 * 3" Legrest Extension interferes with caster swivel when seat is in upright position. Seat must be tilted back at least 5 degrees OR Legrests must be elevated to allow caster swivel. ^ Elevating Legrests with Swing-Away Footplates required. Convaid Safari Tilt - HCPCS E1232 Retail Price List / Order Form Page 1 of 2 4/9/2018

Convaid Safari Tilt - HCPCS E1232 · Safari SFT12 - 900493 $2,365 Safari SFT14 - 901104 $2,365 Safari SFT16 - 900526 $2,365 Safari SFT18 - 902432 $2,365 Upholstery Colors Price SFT12

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Account #:_____________________________________ Purchase Order #:_____________________________ Date:______________________

Contact:______________________________________________ Mark For:_________________________________________________

Bill To: Ship To:

Address: Address:

City/State/Zip:

Phone: Fax: City/State/Zip:

Email: Phone:

Safari Tilt Standard Features: *** Measurements:● 5° to 45° of Adjustable Tilt ● 2-Point Positioning Belt

● Silver Powder Coated Frame ● Heavy-Duty Back Upholstery *** Seat Depth: _____________*

● 7.5 x 2" Front, 11.5 x 2.5" Rear Solid Tire (SFT12/14/16) ● One Piece, Non-Folding/Non-Elevating Footplate

● 6" Front, 11" Rear Solid Tires (SFT18) ● Support Cushion with Solid Seat Insert *** Lower Leg Drop: _________*● Quick Release Rear Wheels (SFT12/14/16) ● Made in the USA

● Wheel Locks *** *if this field is left blank,

*** defaults will be set

Standard Models: Price

Safari SFT12 - 900493 $2,365

Safari SFT14 - 901104 $2,365

Safari SFT16 - 900526 $2,365

Safari SFT18 - 902432 $2,365

Upholstery Colors Price SFT12 SFT14 SFT16 SFT18

Royal Blue $0 903850 903850 903850 903850

Forest Green $0 903857 903857 903857 903857

Cherry Red $0 903855 903855 903855 903855

Sassy Purple $0 903851 903851 903851 903851

Princess Pink $0 903759 903759 903759 903759

Panther Black $0 903854 903854 903854 903854

Chocolate Brown $0 904189 904189 904189 904189

Aqua Blue $0 904753 904753 904753 904753

Apple Green $0 904754 904754 904754 904754

Transit Required Items Price HCPCS SFT12 SFT14 SFT16 SFT18

Transit Option (Manufacturer Installation Required) $200 900494 901141 900527 902435

Headrest Extension $130 E0966 900712 901168 901310 902471

H-Harness with Padded Covers $143 E0960 903988 903988 903988 903988

3-Pt Positioning Belt $49 E0978 904017 904017 904017 904017

Elevating Legrests with Swing-Away Footplates (pair) $270 E0990 900698 901117 901299 902460

Foot Positioners - Select Size Below:

Foot Positioners - Small 7" - 10" (pair) $156 903415 903415 903415 903415

Foot Positioners - Medium 8" - 11" (pair) $156 903416 903416 903416 903416

Foot Positioners - Large 9" - 12" (pair) $156 903417 903417 903417 903417

Transit Options Price HCPCS SFT12 SFT14 SFT16 SFT18

Q'Straint Transit Lap Belt $90 E0978 903095 903095 903095 903095

Sure-Lok Transit Lap Belt $90 E0978 903233 903233 903233 903233

Upper Extremity Support Surface (Foam Tray) Small^ $151 E0950 903669 N/A N/A N/A

Upper Extremity Support Surface (Foam Tray) Medium^ $151 E0950 N/A 903670 903670 N/A

Upper Extremity Support Surface (Foam Tray) Large ̂ $151 E0950 N/A N/A N/A 903671

^ Crash tested Foam Tray with vinyl cover. Flip-Up Armrests required.

Pelvic Positioning Price HCPCS SFT12 SFT14 SFT16 SFT18

3-Pt Positioning Belt $49 E0978 904017 904017 904017 904017

Position Cushion - Medial Thigh Support/Anti Thrust * $347 E2607 903588 903589 903590 903591

Align Cushion - Lateral Pelvis/Lateral Thigh Support * $347 E2607 903592 903593 903594 903595

Incontinence Cushion Liner (Cushion and Solid Seat req) $72 E2619 902324 902324 902324 902324

Solid Seat Insert (Required with Cushion) $119 E0992 904029 904029 904029 904029

* Solid Seat Insert required with any Cushion.

Foot & Leg Positioning Price HCPCS SFT12 SFT14 SFT16 SFT18

Foot Positioners - Small 7" - 10" (pair) ^ $156 903415 903415 903415 903415

Foot Positioners - Medium 8" - 11" (pair) ^ $156 903416 903416 903416 903416

Foot Positioners - Large 9" - 12" (pair) ^ $156 903417 903417 903417 903417

Elevating Legrests w/ Swing-Away Footplates (pair) $270 E0990 900698 901117 901299 902460

Legrest Extension - 3" * ^ $55 N/A 901325 901324 902478

Angle Adj. Footplates - Std Size (pair) ^ $179 K0040 903270 903270 N/A N/A

Angle Adj. Footplates - Adult Size (pair) ^ $179 K0040 N/A N/A 903271 903271

Footplate Securement Strap $30 903584 903584 903584 903584

Medial Thigh Support (Abductor) $162 E0957 900708 901113 901297 902458

Lateral Thigh Support (Adductor) $162 E0956 900709 901145 901298 902459

Calf Panel $61 E0995 904580 904580 904580 904580

* 3" Legrest Extension interferes with caster swivel when seat is in upright position.

Seat must be tilted back at least 5 degrees OR Legrests must be elevated to allow caster swivel.

^ Elevating Legrests with Swing-Away Footplates required.

Convaid Safari Tilt - HCPCS E1232Retail Price List / Order Form

Page 1 of 2 4/9/2018

Retail Price List / Order Form Convaid Safari Tilt - HCPCS E1232

Trunk Positioning Price HCPCS SFT12 SFT14 SFT16 SFT18

H-Harness with Padded Covers (3-Pt Positioning Belt Req) $143 E0960 903988 903988 903988 903988

SA Adj Lateral Support (single flap) with Scoli Strap $137 E0956 900705 901112 901306 902467

SA Adj Lateral Support (double flap) with Scoli Strap $137 E0956 900706 901144 901307 902468

Full Torso Support Vest * $263 900707 901217 901308 902469

Reducer Seat Insert (Reduces Seat Width 2" & Seat Depth 1") $353 904211 904110 904110 904110

* Not available with Single or Double Flap Lateral Support.

Head Supports Price HCPCS SFT12 SFT14 SFT16 SFT18

Padded Headwings $244 E0955 900704 901111 901309 902470

Occi Headwings $228 E0955 905270 905271 905271 905273

Headrest Extension $130 E0966 900712 901168 901310 902471

Frame Option Price HCPCS SFT12 SFT14 SFT16 SFT18

Anatomic Back $335 900697 901164 901319 902476

Recline Option $461 E1225 900689 901139 901321 N/A

Height Adjustable Flip-Up Armrests (pair) $228 E0973 900716 901143 901322 902477

Solid Side Panels (N/A w/ Recline Option) $211 904390 904391 904392 904393

Tire Options Price HCPCS SFT12 SFT14 SFT16 SFT18

12.5" Rear Solid Knobby Tire $199 904117 904117 904117 N/A

7.5" x 2" Front, 12.5" Rear Pneumatic Knobby Tire $299 904118 904118 904118 N/A

12.5" x 2" Rear Solid Knobby Tire $200 N/A N/A N/A 903420

Accessories Price HCPCS SFT12 SFT14 SFT16 SFT18

Headrest Cover (Canopy) $228 900714 901116 901313 902475

Extended Headrest Cover - No Windows (Canopy) $250 904732 904733 904734 904735

Extended Headrest Cover - with Windows (Canopy) $295 904748 904749 904750 904751

Upper Extremity Support Surface (Clear Tray) ̂ $111 E0950 903401 903402 903403 903404

Adj. Removeable Hardware (Required for Clear Tray) $227 E1028 904519 904519 904519 904519

Upper Extremity Support Surface (Foam Tray) Small^ $151 E0950 903669 N/A N/A N/A

Upper Extremity Support Surface (Foam Tray) Medium^ $151 E0950 N/A 903670 903670 N/A

Upper Extremity Support Surface (Foam Tray) Large ̂ $151 E0950 N/A N/A N/A 903671

Wheelchair Travel Bag $206 902022 902022 902022 902022

Utility Bag $38 904531 904531 904531 904531

Curb Tipper (elevates front of chair to go up curbs) $56 904063 904063 904063 904063

Attendant Hand Brakes (pair) * $236 904064 904064 904064 904064

Mosquito Net Size 1 (Canopy req) $150 904655 904655 N/A N/A

Mosquito Net Size 2 (Canopy req) $150 N/A N/A 904656 904656

^ Flip-Up Armrests required.

* Available with Knobby Tires only. Not available with Recline Option.

www.convaid.com Effective: 4/9/2018 Rev 2

Prices in USD & subject to change, ex works Torrance, California.

Standard Domestic Shipping Rate: $40 • For expedited shipping rates, please call 1-888-CONVAID2830 California St., Torrance, CA 90503 • 1-888-CONVAID (266-8243), 310-618-0111 • Fax: 310-618-2166

HCPCS codes are provided for your convenience and are NOT to be considered billing or legal advice. Providers are responsible for insuring that appropriate billing

codes are used when submitting claims. Proper use of HCPCS codes does not insure coverage or payment. Contact the appropriate payer for coverage information.

Page 2 of 2 4/9/2018