View
3
Download
0
Category
Preview:
Citation preview
Page 1 of 2INFINFB4384/RevA/26AUG2021
Go-Go Ultra X, 3-Wheel, Black ..................................... $1,329Part: S39. HCPCS: K0899 — Power Mobility Device, not coded by DME PDAC or does not meet criteria.
Go-Go Ultra X, 4-Wheel, Black ..................................... $1,469Part: S49. HCPCS: K0899 — Power Mobility Device, not coded by DME PDAC or does not meet criteria.
Go-Go® Ultra X 3-Wheel and 4-Wheel Travel Mobility Scooter — Quick Ship Order Form
Pride® Mobility Products Corporation401 York Avenue, Duryea, PA 18642Phone: 1-800-800-8586 | Fax: 1-800-800-1636 | Email: prideorders@pridemobility.com
Account Number: ___________ Date: ________________
Provider Name: __________________________________
Contact: ________________________________________
Phone: ___________________ Fax: _________________
Email: __________________________________________
PO Number: _____________________________________
Marked for: _____________________________________
Ship to Address: _________________________________
City: _____________________ State: ______ Zip: ______
ACCESSORIESOptional.
Micro Black Weather Cover ...............................................$140Part: ACCCOVR1020
Cup Holder ............................................................................ $30Part: ACCASMB2288
50″ Lap Belt ................................................................ StandardPart: ACCBELT1000
Safety Flag ............................................................................ $38Part: ACCASMB2079
Saddle Bag (12.5″ × 9.875″) .................................................. $40Part: DWR1020D010
Under-Seat Storage ............................................................. $80Part: ACC160129
2.1A XLR USB Charger ...................................................$42.99Part: KIT2001524
Rearview Mirror .................................................................... $25Part: ACC134496
MODELREQUIRED. Weight capacity: 300 lbs. Find more details and specifications at pridemobility.com/go-go-ultra-x-3-wheel or pridemobility.com/go-go-ultra-x-4-wheel.
Standard Features
• 12Ah battery pack
• 2-amp off-board charger
• Front basket
• 8″ flat-free tires
• Mesh-back seat (17″W × 17″D)
INTRODUCTIONThis 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 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 scooter. Pride Providers may contact Technical Services for accurate parts ordering.
Thank you for choosing Pride Mobility Products!
FDA Class II Medical Device*
Back-Mounted AccessoriesOptional. Only one back-mounted accessory can be used at a time. Includes mounting bracket and hardware.
Rear Basket (15.25″ × 9.75″ × 9.5″) . $90 Part: ACCBSKT1010
Oxygen Tank Holder ...................... $98Part: ACCASMB1017
Walker Holder ................................. $98Part: ACCASMB1018
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
Page 2 of 2INFINFB4384/RevA/26AUG2021
COMMENTS
© 2021 Pride Mobility Products Corp. All rights reserved.
Pride® Mobility Products Corporation401 York Avenue, Duryea, PA 18642Phone: 1-800-800-8586 | Fax: 1-800-800-1636 | Email: prideorders@pridemobility.com
youtube.com/pridemobility
facebook.com/PrideMobilityProductsCorp
twitter.com/pridemobility
instagram.com/PrideMobilityProducts
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® Travel Mobility Scooters are FDA Class II Medical Devices designed to aid individuals with mobility impairments.
CANE/CRUTCH HOLDEROptional. Only one cane/crutch holder can be used at a time.
Wishbone Crutch Holder .................................................... $98Part: FRMASMB2358
Forearm Crutch Holder ....................................................... $98Part: ACCASMB1019
Single Rear Mount, 3″...........................................................$70Part: ACCINDV1058
Double Rear Mount, 3″ .........................................................$70Part: ACCINDV1019
Recommended