The realm of assistive technology encompasses a diverse array of forms and documents, crucial for ensuring that individuals receive products tailored to their unique needs. The Convaid Vivo Retail Price List / Order Form epitomizes this vital aspect of healthcare and accessibility services. This comprehensive document details everything from account and purchase order information to the specific features and customizations available for the Convaid Vivo wheelchair, a device designed to enhance the mobility of individuals requiring additional support. Among the form's highlights are the enumeration of the Vivo's standard features, such as adjustable recline, swing-away footplates, and a myriad of upholstery color options, alongside the finer details like optional accessories and positioning supports, which are essential for customizing the wheelchair to the user's precise needs. Furthermore, this form lists the prices of various wheelchair configurations and accessories, providing a transparent overview of costs. Each section is meticulously designed to ensure clarity and ease of use, with additional notes on shipping rates and contact information for Convaid, making it an indispensable tool for providers and users alike. By delineating this wealth of information, the form serves not merely as a transactional document but as a bridge to greater independence and quality of life for those it serves.
| Question | Answer |
|---|---|
| Form Name | Convaid Vivo Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | vivo all model battery list, vivo mobile model list pdf, vivo model name list, all mobile battery model list pdf |
Convaid Vivo
Retail Price List / Order Form
Account #:_____________________________________ |
Purchase Order #:_______________________ Date:______________________ |
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Contact:______________________________________________ |
Mark For:_________________________________________________ |
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Bill To: |
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Ship To: |
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Address: |
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Address: |
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City/State/Zip: |
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Phone: |
Fax: |
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City/State/Zip: |
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Email: |
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Phone: |
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Vivo Standard Features: |
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Measurements: |
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● Toggle Wheel Locks |
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● 95 to 120 Degrees of Adjustable Recline |
● Closure Strap |
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Seat Depth: _____________* |
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● Removable Adjustable |
● Adjustable Back Upholstery |
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● Made in the USA |
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Lower Leg Drop: _________* |
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● 6" Front, 8" Rear Solid Tire |
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*if this field is left blank, |
Standard Models: |
Price |
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defaults will be set |
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VIVO VV12 - 904640 |
$900 |
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VIVO VV14 - 904641 |
$920 |
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VIVO VV16 - 904642 |
$975 |
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Upholstery Colors - Cordura |
Price |
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Royal Blue |
$0 |
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Forest Green |
$0 |
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Cherry Red |
$0 |
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Sassy Purple |
$0 |
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Princess Pink |
$0 |
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Panther Black |
$0 |
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Chocolate Brown |
$0 |
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Aqua Blue |
$0 |
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Apple Green |
$0 |
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Tangerine Orange |
$0 |
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Pelvis Positioning |
Price |
HCPCS |
$49 |
E0978 |
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Foot & Leg Positioning |
Price |
HCPCS |
Foot Positioners - Small 7" - 10" (pair) |
$156 |
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Foot Positioners - Medium 8" - 11" (pair) |
$156 |
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Footplate Securement Strap |
$30 |
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Medial Thigh Support (Abductor) |
$162 |
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Lateral Thigh Support (Adductor) |
$162 |
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Calf Panel |
$61 |
E0995 |
Trunk Positioning |
Price |
HCPCS |
$143 |
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Anterior Trunk Support |
$191 |
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Head Supports |
Price |
HCPCS |
Occi Headwings |
$228 |
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Headrest Extension |
$130 |
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Frame Option |
Price |
HCPCS |
Height Adjustable |
$203 |
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Long Seat Depth |
$0 |
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Long Back Height |
$0 |
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Accessories |
Price |
HCPCS |
Headrest Cover (Canopy) |
$228 |
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Grab Bar ^ |
$151 |
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Travel Bag (For Wheelchair Only) |
$206 |
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Upper Extremity Support Surface (Padded Tray) ^ |
$101 |
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Adjustable Removable Hardware (Req. for Padded Tray) |
$0 |
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^ Armrests required.
VV12 |
VV14 |
VV16 |
903850 |
903850 |
903850 |
903857 |
903857 |
903857 |
903855 |
903855 |
903855 |
903851 |
903851 |
903851 |
903759 |
903759 |
903759 |
903854 |
903854 |
903854 |
904189 |
904189 |
904189 |
904753 |
904753 |
904753 |
904754 |
904754 |
904754 |
904752 |
904752 |
904752 |
VV12 |
VV14 |
VV16 |
904017 |
904017 |
904017 |
VV12 |
VV14 |
VV16 |
903415 |
903415 |
903415 |
903416 |
903416 |
903416 |
903584 |
903584 |
903584 |
903429 |
903561 |
904544 |
903430 |
903562 |
904545 |
903454 |
903563 |
904546 |
VV12 |
VV14 |
VV16 |
903988 |
903988 |
903988 |
903455 |
903564 |
904547 |
VV12 |
VV14 |
VV16 |
903433 |
903433 |
903433 |
903460 |
903566 |
904553 |
VV12 |
VV14 |
VV16 |
903438 |
903557 |
904548 |
904643 |
904644 |
904645 |
N/A |
904646 |
N/A |
VV12 |
VV14 |
VV16 |
903436 |
903569 |
904549 |
903437 |
903570 |
904550 |
902022 |
902022 |
902022 |
903435 |
903568 |
904551 |
904119 |
904120 |
904552 |
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Price |
HCPCS |
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Standard Upholstery. Select Color from above __________. |
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Seat Upholstery * |
$90 |
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Back Upholstery * |
$90 |
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Long Upholstery. Select Color from above __________. |
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Long Seat Upholstery * |
$90 |
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Long Back Upholstery * |
$90 |
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* Matching Seat Bottom Upholstery or Back Upholstery required.
VV12 |
VV14 |
VV16 |
994050 |
994150 |
995850 |
994038 |
994138 |
995838 |
994051 |
994151 |
995851 |
N/A |
994152 |
N/A |
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.
Standard Domestic Shipping Rate: $40 • For expedited shipping rates, please call
2830 California St., Torrance, CA 90503 •
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Prices in USD & subject to change, ex works Torrance, California. |
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www.convaid.com |
Effective: 7/24/2014 |
Rev 5 |
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Page 1 of 1 |
7/24/2014 |