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

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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

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

Page 1 of 6

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.

FRAME SELECTIONS

Revised August 28, 2013

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

Page 2 of 6

FXMYONJR Myon JR Fixed Width Model ............... $1,849.00GRMYONJR Myon JR Growable Width Model ........ $1,849.00

FRAME TYPE (175 lbs weight capacity)

E1238

E1238

SWR811 Adjustable Seat Width 8 - 11".............................. No Charge

SWR1215 Adjustable Seat Width 12 - 15"............................ No Charge

SEAT WIDTH RANGE

Available with SDR810, SDR1012, and SDR1214. Excludes TRBKTS.

Available with SDR1113, and SDR1315.

W08 8'' Wide .................................................................. No Charge

W09 9" Wide ................................................................... No Charge

W10 10'' Wide ................................................................ No Charge

W11 11'' Wide ................................................................ No Charge

W12 12'' Wide ................................................................ No Charge

W13 13'' Wide ................................................................ No Charge

W14 14'' Wide ................................................................ No Charge

W15 15" Wide ................................................................ No Charge

SEAT WIDTH

W08 not available with SDR1113 and SDR1315, on GRMYONJR.

W09 not available with SDR1113 and SDR1315, on GRMYONJR.

W10 not available with SDR1113 and SDR1315, on GRMYONJR.

W11 not available with SDR1113 and SDR1315, on GRMYONJR.

W12 not available with SDR810, SDR1012, and SDR1214, on GRMYONJR. W12 not available with D15, on FXMYONJR.

W13 not available with SDR810, SDR1012, and SDR1214, on GRMYONJR. W13 not available with D12 and D13, on FXMYONJR.

W14 not available with SDR810, SDR1012, and SDR1214, on GRMYONJR. W14 not available with D12 and D13, on FXMYONJR.

W15 not available with SDR810, SDR1012, and SDR1214, on GRMYONJR.

SDR810 Adjustable Seat Depth 8 - 10" .............................. No ChargeSDR1012 Adjustable Seat Depth 10 - 12" ............................ No ChargeSDR1214 Adjustable Seat Depth 12 - 14" ............................ No ChargeSDR1113 Adjustable Seat Depth 11 - 13" ............................ No ChargeSDR1315 Adjustable Seat Depth 13 - 15" ............................ No Charge

SEAT DEPTH RANGE

D08 8'' Seat Depth ......................................................... No Charge D09 9'' Seat Depth .......................................................... No ChargeD10 10'' Seat Depth ........................................................ No ChargeD11 11'' Seat Depth ........................................................ No ChargeD12 12'' Seat Depth ........................................................ No ChargeD13 13'' Seat Depth ........................................................ No ChargeD14 14'' Seat Depth ........................................................ No ChargeD15 15'' Seat Depth ........................................................ No Charge

SEAT DEPTH

Invacare® MYON™ JR Ultralightweight Folding Wheelchair

Form No. 11-088

SEAT WIDTH x SEAT DEPTH MatrixW08 W09 W10 W11 W12 W13 W14 W15

D08 X X X X

D09 X X X X

D10 X X X X

D11 X X X X X X X X

D12 X X X X X X X XD13 X X X X X X X X

D14 X X X X X X X X

D15 X X X XX= Compatible

TRBKTS Transport Brackets ............................................ $150.00

TRANSPORT OPTION

Not available on SWR811 Not available with the following wheel and seat height combinations: 20'' Rear Wheel at RSTF 14 and 15 22'' Rear Wheel at RSTF 15 and 16 Only available with Elevating Legrests with Calf Pads

Transport 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. 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. Invacare cannot and does not recommend any wheelchair transportation systems.

Form No. 11-088

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

Page 3 of 6Revised August 28, 2013

REAR WHEEL SELECTIONS

WHEEL OPTIONS (Pair)

20COM 20" Composite Wheels ........................................... No Charge22COM 22" Composite Wheels ........................................... No Charge

L8701 Omit Rear Wheels ............................................... Less $50.0022ITESPK 22" Lightweight Performance Stylized Wheel ..... No Charge

TIRE OPTIONS (Pair)PNEU Pneumatic Tires .................................................... $60.00PNEUFF Flat Free Inserts .................................................... $65.00URETH Urethane (treated) Tires ................................. No ChargePRIMO Primo Tires ............................................................ $60.00PRIMOTRD Primo 559 Treated Pneumatic ........................... $60.00KIKB KIK® Black Tires................................................... $60.00

E2213

CRF123 Schwalbe Marathon Plus ....................................... $90.00 E2213

HANDRIM OPTIONS (Pair)ALUMPC Aluminum Anodized Handrim ..................... No ChargeBLKANO Black Anodized Handrim ............................ No ChargeA1512 Black Plastic Coated Handrims .......................... $72.00L8702 Omit Handrims .............................................. Less $15.00

K0059

FORK SELECTIONSFORK OPTIONS (Pair)

FRKL1 Super Low, 1 Hole Fork ......................................... No ChargeFRKS2 Normal Range 2 Hole Fork .................................... No Charge

Rear Wheel Tire Options Handrim Options

20COM PNEU, PNEUFF, URETH ALUMPC, A1512

22COM PNEU, PNEUFF, URETH ALUMPC, A1512, AT1225-8

22ITESPK PNEU, PNEUFF ALUMPC,A1512,

FSTF Caster Options Fork Options

FSTF15 5ALUM, AT901 FRKL1, FRKS2

FSTF16 5ALUM, AT901, AT5SOFT, AT902, 6PNEU Only FRKS2

FSTF17 5ALUM, AT901, AT5SOFT, AT902, 6PNEU Only FRKS2

FSTF18 5ALUM, AT901, AT5SOFT, AT902, 6PNEU Only FRKS2

CASTER OPTIONS (Pair)5ALUM 5'' Aluminum Urethane Caster ..................................... $92.00AT901 5" Composite Urethane ...........................................No Charge AT5SOFT 5"x 1 1/2" Wide Soft Roll .................................... No ChargeAT902 6'' Composite Urethane 3 Spokes ........................... No Charge6PNEU 6'' x 1 1/4" Composite Pneumatic ................................. $64.00AT903 8" x 1 1/4" Composite Urethane Casters ................No ChargeAT1292 8" x 1 1/4" Composite Pneu Casters ............................ $86.001492 8" x 1 1/4" Pneu w/ Flat Free Insert ........................... $182.00

CASTER SELECTIONS

Invacare® MYON™ JR Ultralight Folding Wheelchair

FRAME FINISH SELECTIONS24P Wet Black ............................................................... 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 Charge

117P Tangerine Red ........................................................ No Charge127P Grasshopper Green ................................................. No Charge

116P Sunkissed Orange ................................................... No Charge29P White Snow ............................................................ No Charge

CENTER OF GRAVITY SETTING

ACG1 Center Gravity +1 (0 is back canes) ....................... No ChargeACG0 Center Gravity 0 (0 is back canes) ......................... No Charge

ACG2 Center Gravity +2 (0 is back canes) ....................... No Charge

ACG-1 Center Gravity -1 (0 is back canes) ........................ No Charge

Please select a center of gravity setting. Center of gravity is measured from the front of the back post to the center of the axle.

REAR SEAT-TO-FLOOR HEIGHT

RSTF14 14" Seat-to-Floor Height ........................................ No ChargeRSTF15 15" Seat-to-Floor Height ........................................ No ChargeRSTF16 16" Seat-to-Floor Height ........................................ No ChargeRSTF17 17" Seat-to-Floor Height ........................................ No ChargeRSTF18 18" Seat-to-Floor Height ........................................ No Charge

RSTF13 13" Seat-to-Floor Height ........................................ No ChargeMaximum 2" difference from Front Seat-to-Floor Height

FSTF15 15" Seat-to-Floor Height ........................................ No Charge

FSTF16 16" Seat-to-Floor Height ....................................... No Charge

FSTF17 17" Seat-to-Floor Height ........................................ No ChargeFSTF18 18" Seat-to-Floor Height ........................................ No Charge

FRONT SEAT-TO-FLOOR HEIGHT

Available with 80STSSHORT0, 80STRSHORT30, 80STRLONG0, 80STRLONG30.

Available with 80STSSHORT0, 80STRSHORT30, 80STRLONG0, 80STRLONG30.

Revised August 28, 2013

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

Page 4 of 6

POSITIONING STRAPS/ACCESSORIESSEAT POSITIONING STRAPS (Each)

E0978

E0978

A1515 Push Button Buckle Seat Pos. Seat .................... $50.00

A1321BK Hook & Loop Seat Pos. Seat .............................. $40.00Available on W11 and wider.

Available on W11 and wider.

MISCELLANEOUS ACCESSORIESA1307 Spoke Protector (For 20", 22", 24", 26") ....... $90.00

1209 Tire Pump ........................................................... $35.00A1580 Rear Anti-Tippers (pair) .................................... $60.00A1580P Rear Anti-Tippers w/ Obstacle Climb Aid ........ $60.00A1569 Cane Holder ....................................................... $46.00

A1307SM Smiley Spoke Protector (For 20", 22") .......... $90.00A1307SP Spider Spoke Protector (For 20", 22") ........... $90.00A1307SFL Flower Spoke Protector (For 20", 22") .......... $90.00

STBKIT Stabilizer Kit ...................................................... $85.00TUCLR Touch-Up Paint Colors ..................................... $20.00

K0065

K0065

K0065

K0065

E0971

E0971

E2271

Form No. 11-088

L8651 Omit Seat Upholstery ........................................... Less $10.00ADJWDS Adj Width & Depth Sail Cloth .................................. Standard

SEAT UPHOLSTERY TYPE

ARM TYPE (Pair)TAD T-Arms, Adj Height Desk Length ............... $225.00TAHJ T-Arms, Adj Height Junior Style ................ $225.00LESSARMS Less Arms ......................................... Less $24.00

E0973/each

E0973/each

TAHJ T Arm Adjustable Height Junior Style

TAD T Arm Adjustable Height Desk Length

ABH1519PH 15"-19" Range, Straight Cane ....................... No Charge

ADJUSTABLE HEIGHT WITH PUSH HANDLES

8BEND Add 8 Degree Bend ..................................... No Charge

ABH1519 15"-19" Range, Straight Cane .............................. No Charge

ADJUSTABLE HEIGHT WITHOUT PUSH HANDLES

8BEND Add 8 Degree Bend ............................................ No Charge

AABH1519 15"-19" Range, Straight Cane ..................... $165.00

ADJUSTABLE ANGLE BACK WITH PUSH HANDLES

8BEND Add 8 Degree Bend ................................. No Charge K0108

ADJWHB Adj Width & Height Nylon Back Upholstery ........ No Charge

L8601 Omit Back Upholstery ...................................... Less $10.00

BACK UPHOLSTERY TYPE

Includes backbrace. Not available with stroller handle.

Does not include backbrace.

BACK SELECTIONS

FBH16 16" w/ Push Handles, 0 Degree Bend .................... No Charge FBH14 14" w/ Push Handles, 0 Degree Bend .................... No Charge

FIXED HEIGHT

8BEND Add 8 Degree Bend .............................................. No Charge

FBH16F 16" Folding Back Canes, 8 Degree Bent ............. $65.00 FBH17F 17" Folding Back Canes, 8 Degree Bent ............. $65.00

FIXED HEIGHT FOLDING BACK CANESK0108

K0108

ARM SELECTIONS

UPHOLSTERY SELECTIONS

CHEST POSITIONING STRAPS (Each)E0960

E0960

9515 Push Button Style Chest Positioning Chest ...... $100.00Available on W11 through W15.

Available on W11 through W15.7321 Hook & Loop Chest Positioning Chest ............... $40.00

Invacare® MYON™ JR Ultralight Folding Wheelchair

WHEEL LOCKS

K0064

WLPULL Pull to Lock Clam-On Wheel Locks .............. No ChargeWLPUSH Push to Lock Wheel Locks ............................. No ChargeWLPULLX Pull to Lock Wheel Lock w/ Extension ............. $60.00WLPUSHX Push to Lock Wheel Lock w/ Extension ............ $60.00L8704 Omit Wheel Locks ....................................... Less $10.00

E0961

E0961

WHEEL LOCK SELECTIONS

AXLES (Pair)A1577 Quick Release Axles with Dome ........................... No Charge

A1573 Quad Release Axles ............................................. $89.00PAXLE Permanent Axles .................................................... No Charge

Only available with FN1624 Sun Fusion rear wheels. K0108

MOUNTING HANDRIMS (Spoke Wheels Only)IN Mount Inside Handrim ........................................... No ChargeOUT Mount Outside Handrim ........................................ No Charge

CAMBER ANGLEC00 0° Camber ............................................................... No ChargeC03 3° Camber .............................................................. No Charge

Revised August 28, 2013 Form No. 11-088

Invacare® MYON™ JR Ultralight Folding Wheelchair

FOOTREST/LEGREST ACCESSORIESA1337 Calf Strap (each) ................................................. $24.00 K0038

FRMPRBK ChairArmor Black Frame Protectors ............... $65.00

K0039

E0951

FRMPRR ChairArmor Red Frame Protectors ..................... $65.00FRMPRS ChairArmor Silver Frame Protectors .................. $65.00

HLOOP Heel Loop w/o Ankle Straps (pair) ..................... $51.00A9342 "H" Strap (each) .................................................. $51.00

FRMPRB ChairArmor Blue Frame Protectors .................... $65.00

BRCVR Bear Cover for 90 Degree Lift Off ..................... $20.00MYCVR Monkey Cover for 90 Degree Lift Off ................ $20.00

FRONT RIGGING SELECTIONSFRONT RIGGING (Pair)

ELVOFFWO Lift Off Elev Front Riggings,w/o Calf Pad . $255.00

80STRLONG30 80° Swing in/out Hanger, Long, 30° ... No Charge

90STRLIFT 90° Lift Off Hanger (Black only)............... No Charge

ELVOFF Lift Off Elevating Front Riggings, w/ Calf Pad . $255.00

80STRSHT0 80° Swing in/out Hanger, Short, ...... No Charge

80STRSHT30 80° Swing in/out Hanger, Short, 30° .... No Charge

80STRLONG0 80° Swing in/out Hanger, Long, 0° ..... No Charge

Not available with FLIPFTS or TRBKTS

Not available with 1PCFTPT, FSTF15 or FSTF16

Not available with 1PCFTPT

E0990

E0990

90STRLIFT ELVOFF 80STRSHT0

0° Abduction

30° Abduction

Not available with TRBKTS

Not available with TRBKTS

Not available with TRBKTS

Not available with TRBKTS

INDIVIDUAL FOOTPLATE TYPE

FLDPADJ Flip-Up Adjustable Depth/Angle Footplates .. $165.00FLIPFTS Flip-Up Composite Footplates ...................... No Charge

K0040/Each

ONE PIECE FOOTPLATE TYPE1PCFTPT One Pc. Adjustable Angle Flip Up Footplate .... $165.00 K0040

1PCFTPT One Piece Adjustable Angle Flip Up Footplate

ARM ACCESSORIES (Pair)REMG Removable Mudguard ...................................... $122.00RESK Removable Skirtguard - Bear Shape ................. $122.00Not available with FSTF15.

K0108

K0108

RESK Removable Skirtguard - Bear Shape

REMG Removable Mudguard

SEAT ACESSORIES

ACTRSA Right Side Swingaway Acrylic Lap Tray ......... $130.00

SP01 Seat Pouch ............................................................ $35.00

ACTLSA Left Side Swingaway Acrylic Lap Tray ............ $130.00STRHNDL Adjustable Stroller Handle ............................. $150.00

ACTRY Acrylic Lap Tray ............................................... $199.00 E0950

E0950

E0950

K0108

BACK ACCESSORIESBP02 Back Pack ..................................................................... $50.00

FLDPADJ Flip-Up Adjustable Depth/Angle Footplates

KNEE-TO-HEEL RANGE

Front Rigging Type Range

80° Swing In/Out Hangar, Short, 0° Abduction With FLPFTS - 7.75"-12.75"

80° Swing In/Out Hangar, Short, 30° Abduction

80° Swing In/Out Hangar, Long, 0° Abduction With FLPFTS - 12"-15"80° Swing In/Out Hangar, Long, 30° Abduction

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

Page 6 of 6

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

©2010 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. Freedom Designs is a registered trademark of Freedom Design, Inc.

Comments

SEATING CUSHION SELECTION

E2605

E2607

E2607

E2606

E2601

E2601E2602

ITSG Matrx Stabilite Cushion ..................................... $320.00

ITFG Matrx Flovair Gentle Contour Cushion ............. $390.00

ITFM Matrx Flovair Max Contour Cushion ................ $390.00

Clear

SD Invacare Single Density Cushion ....................... $170.00

EC Invacare Absolute Cushion ................................ $104.00

E2608

Width sizes: 16", 18" and 20". Depth sizes: 16" and 18".

Width sizes: 10" through 24". Depth sizes: 7" through 20".

Width sizes: 14" through 24". Depth sizes: 14" through 22".

Width sizes: 15" through 24". Depth sizes: 15" through 22".

E2608Width sizes: 15" through 24". Depth sizes: 15" through 22".

SEATING

For additional seating needs please refer to the following: Invacare Matrx Seating and Positioning Products Price List Form

#11-036. Please contact Invacare Customer Service to ship Invacare Matrx

Seating options with your chair order.

Invacare® Myon™ Jr. Ultralight Folding Wheelchair