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Page 1 of 2INFINFB3764/RevD/07MAY2018
Go-Go Elite Traveller® Plus- 3 and 4 Wheel Scooter, Quick Ship Order Form
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: ______
Rear Basket (15.25" x 9.75" x 9.5") .................................... $80 Part: ACCBSKT1010
Oxygen Holder ..................................................................... $98Part: ACCASMB1017
Walker Holder ....................................................................... $98Part: ACCASMB1018
MODELREQUIRED. 300 lb. weight capacity. More details and specifications at found at pridemobility.com/scooters.
Go-Go Elite Traveller Plus, 3-Wheel ............................ $1,649Part: SC53. HCPCS: K0806 - Group 2/Standard
Go-Go Elite Traveller Plus, 4-Wheel ............................ $1,899Part: SC54. HCPCS: K0806 - Group 2/Standard
Includes standard options:• Red, Blue shroud panels• Two 18 Ah Extended Range batteries• 3.5-Amp off-board charger• Front Basket• Flat-free tires• Foldable, Molded plastic seat (17"W x 17"D)
ACCESSORIESOptional.
Micro, Black, Weather Cover .............................................$114Part: ACCCOVR1020
Rear View Mirror .................................................................. $25Part: ACC134496
Cup Holder ............................................................................ $20Part: ACCASMB2288
50" Lap Belt ................................................................ StandardPart: ACCBELT1000
Safety Flag ............................................................................ $38Part: ACCASMB2079
Saddle Bag (12.5" x 9.875") ................................................ $35Part: DWR1020D010
Under Seat Storage ............................................................. $80Part: ACC160129
Cell Phone Holder .................................................................$70Part: ACC145549
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 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. 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.
Page 2 of 2INFINFB3764/RevD/07MAY2018
Account Number: ___________ Date: ________________ Marked for: _____________________________________
COMMENTS
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
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
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
Pride® Mobility Products Corporation182 Susquehanna Ave Exeter, PA 18643Phone: 800-800-8586 | Fax: 800-800-1636 | Email: [email protected]
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
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