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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

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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