go go folding scooter order form - pride mobility · title: go go folding scooter order form...
TRANSCRIPT
Page 1 of 1INFINFB3740/RevB/09OCT2017
Pride® Mobility Products Corporation182 Susquehanna Ave Exeter, PA 18643Phone: 800-800-8586 | Fax: 800-800-1636 | Email: [email protected]
Account Number: ___________ Date: ________________
Provider Name: __________________________________
Contact: ________________________________________
Phone: ___________________ Fax: _________________
Email: __________________________________________
PO Number: _____________________________________
Marked for: _____________________________________
Ship to Address: _________________________________
City: _____________________ State: ______ Zip: ______
Go Go® Folding Scooter, Order Form
ACCESSORIESOptional.
Arm Rests (pair) ....................................................................................................................................................................................$159Part: ARM150059
MODELREQUIRED. 250 lb. weight capacity. Includes grey vinyl seat (16"x13") and flat-free tires. More details and specifications at found at pridemo-bility.com/gogo.
Go-Go Folding Scooter, White, with Sealed Lead Acid Batteries. ............................................................................................ $2,499Includes two 12 volt batteries and a 2 amp off-board chargerPart: S19WH1001. HCPCS: K0899 - Power Mobility Device, not coded by DME PDAC or does not meet criteria.
Go-Go Folding Scooter, White, with Lithium Ion Batteries. ....................................................................................................... $2,899Includes one 24 volt battery and a 2.5 amp off-board charger Part: S19WH1002. HCPCS: K0899 - Power Mobility Device, not coded by DME PDAC or does not meet criteria.
Air Force Patch ............................... $20Part: ACC140240
Army Patch ..................................... $20Part: ACC140241
Coast Guard Patch ........................ $20Part: ACC140239
Marines Patch ................................. $20Part: ACC140243
Navy Patch ...................................... $20Part: ACC140244
Purple Heart Patch ........................ $20Part: ACC140238
BRANCH PATCHESOptional.
Air Force Patch ............................... $20Part: ACC140240
Army Patch ..................................... $20Part: ACC140241
Coast Guard Patch ........................ $20Part: ACC140239
Marines Patch ................................. $20Part: ACC140243
Navy Patch ...................................... $20Part: ACC140244
Purple Heart Patch ........................ $20Part: ACC140238
NOTES
Mobility Made Easy. Pride offers a variety of lifts to transport your mobility product with ease. To find a compatible lift for your vehicle and mobility product, use our new Lift Finder applica-tion at pridemobility.com/lift-finder
© 2017 Pride Mobility Products Corp. All rights reserved.
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This form is interactive when viewed in 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 deter-mining the appropriate billing codes when submitting for insurance reim-bursement. 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 scooter. Please contact technical service for accurate parts ordering.
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