Page 1 of 2INFINFB3877/RevB/13NOV2017

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Viva Lift Power Recliners, Order Form

Pride Mobility Products Corp.182 Susquehanna Ave., Exeter, PA 18643Phone: 800-800-8586 | Fax: 800-800-1636 | Email: prideorders@pridemobility.com

Account Number: ___________ Date: ________________

Provider Name: __________________________________

Contact: ________________________________________

Phone: ___________________ Fax: _________________

Email: __________________________________________

PO Number: _______________ Marked for: ____________

Ship to Address: _________________________________

City: _____________________ State: ______ Zip: ______

Elegance ............................................................................................................................................................................................$1,699Part: PLR975MMODEL. HCPCS: E0627 - seat lift mechanism, electric, any type.5'4" to 6' height range, 22" seat width.

This form is interactive when viewed with Adobe Acrobat Reader and may not function correctly if opened with applications other than Acrobat. HCPCS codes provided should not be considered as legal advice and do not guarantee reimbursement. DME providers are responsible for determining the appropriate billing codes when submitting for insurance reimbursement. Payer coding, coverage, and bundling guidelines may apply. All prices are MSRP. Prices, specifications, part numbers, and availability are subject to change without notice. Prices and part numbers as shown are only available when configured as a complete power lift recliner. Please contact technical service for accurate parts ordering.

Thank you for choosing Pride® Mobility Products!

Introduction

Viva Lift Collection single chair orderSelect model and fabric color below. 375 lbs. weight capacity, Infinite Lay Flat position chaise lounger.

See Multiple Chair Order on page 2

Urbana ................................................................................................................................................................................................$1,699Part: PLR965MMODEL. HCPCS: E0627 - seat lift mechanism, electric, any type.5'4" to 6' height range, 21" seat width.

Perfecta ..............................................................................................................................................................................................$1,599Part: PLR945MMODEL. HCPCS: E0627 - seat lift mechanism, electric, any type.5'4" to 6' height range, 22" seat width.

Metro ...................................................................................................................................................................................................$1,599Part: PLR925MMODEL. HCPCS: E0627 - seat lift mechanism, electric, any type.5'4" to 6' height range, 21" seat width.

Badlands Fabrics: Walnut ..............StandardPart: FABVBW

Stonewash Fabrics: Gunmetal .........StandardPart: FABVSG

Merino Fabrics: Steel .................StandardPart: FABVMS

Saville Fabrics: Grey .................StandardPart: FABVSY

Mushroom .......StandardPart: FABVBM

Granite .............StandardPart: FABVSR

Fawn.................StandardPart: FABVML

Brown ..............StandardPart: FABVSB

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Select upgrades and accessories for a single chair orderProtective Pad ...................................................................... $30Part: ACCASMB2514

Residential Clening Kits ....................................$39.90 ea.Part: ACCASMB2479

Page 2 of 2INFINFB3877/RevB/13NOV2017

Account Number: ___________ Date: ________________ Marked for: _____________________________________

© 2017 Pride Mobility Products Corp. All rights reserved.

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Multiple Chair OrderPlease see page 1 for pricing, details, and limitations. Enter a quantity below and then place check marks in the field with the desired option.

Relaxed PositionThe Relaxed Position can be achieved on all Pride Viva Lift Power Recliners. This features elevated footrest and sightly reclined backrest.

Infinite Lay Flat PositionInfinite lay flat position Pride, Viva Lift Power Recliners enable the backrest and footrest to move independently from one another so that a variety of positions can be reached.

Reclined PositionThe Reclined Position can be achieved on Viva Lift Power Recliners after fully elevating the legrest. Infinite Position chairs can operate legrest and backrest independently.

Power Lift Recliner Position ReferenceThe Viva Lift Power Recliners are Infinite Lay Flat position chaise loungers. The infinite lay flat position allows the backrest and footrest to move independently from one another so that a variety of positions can be reached, including Relaxed and Reclined positions.

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Kit

QTY Model BadlandsFabrics

StonewashFabrics

SavilleFabrics

MerinoFabrics

Upgrade & Accessories