gogo sport order form - pride mobility · title: gogo sport order form author: sara chesbrough...
TRANSCRIPT
Page 1 of 2INFINFB3721/RevF/01MAY2018
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® Sport 3 and 4 Wheel, Quick Ship Order Form
MODELREQUIRED. 325 lb. weight capacity. More details and specifications at found at pridemobility.com/scooters.
Go-Go Sport 3-wheel, Red and Blue...........................$1,899Part: S73. HCPCS: K0801 - Group 1 Heavy Duty.
Go-Go Sport 4-wheel, Red and Blue. .........................$1,949Part: S74. HCPCS: K0801 - Group 1 Heavy Duty.
Includes Standard Options:• 18 Ah Extended Range Battery Pack• 3.5 AMP Off-board Charger• Flat-free tires• Foldable, Molded Plastic Seat (17"W x 17"D)• Front Basket
ACCESSORIESOptional.
Oxygen Holder ............................... $98Part: ACCASMB1017
Rear Basket .................................... $80 (15.25" x 9.75" x 9.5")Part: ACCBSKT1010
Walker Holder ................................. $98Part: ACCASMB1018
Wishbone Crutch Holder .............. $98Part: FRMASMB2358
Single Rear Mount, 3" ................... $70Part: ACCINDV1058
Double Rear Mount, 3" .................. $70Part: ACCINDV1019
Cell Phone Holder .......................... $70Part: ACC145549
Cup Holder, C Style ....................... $20Part: ACCASMB2288
Rear View Mirror ............................ $25Part: LGTRMIR1003
Saddle Bag ...................................... $35Part: DWR1020D010
Safety Flag ...................................... $38Part: ACCASMB2079
Under Seat Storage ....................... $80Part: ACC160128
Weather Cover, Black ...................$114Part: ACCCOVR1020
50" Lap Belt ........................No ChargePart: ACCBELT1000
Throttle Pot Reversal ................... $100Part: PTOINDV3601
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 determining the ap-propriate 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 scooter. Please contact technical service for accurate parts ordering.
Thank you for choosing Pride Mobility Products!
INTRODUCTION
Back Mounted AccessoriesOptional. Only one back mounted accessory can be used at a time. Includes mounting bracket and hardware.
Cane/Crutch HoldersOptional. Only one cane/crutch holder can be used at a time. Includes mounting bracket and hardware.
Page 2 of 2INFINFB3721/RevF/01MAY2018
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
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
Pride® Mobility Products Corporation182 Susquehanna Ave Exeter, PA 18643Phone: 800-800-8586 | Fax: 800-800-1636 | Email: [email protected]© 2018 Pride Mobility Products Corp. All rights reserved.
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Account Number: ___________ Date: ________________ Marked for: _____________________________________
COMMENTS
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