Victory 10 Order Form - Pride Mobility · 2020-02-21 · Victory® 10 Order Form — 3-Wheel and...
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Page 1 of 3 INFINFB3737/RevE/03FEB2020 Victory ® 10 Order Form — 3-Wheel and 4-Wheel Scooters Pride ® Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA 18643 Phone: 1-800-800-8586 | Fax: 1-800-800-1636 | Email: [email protected] Account Number: ___________ Date: ________________ Provider Name: __________________________________ Contact: ________________________________________ Phone: ___________________ Fax: _________________ Email:__________________________________________ PO Number:_____________________________________ Marked for: _____________________________________ Ship to Address: _________________________________ City: _____________________ State: ______ Zip: ______ COLOR REQUIRED. Colors shown here may differ from actual product depending on monitor/printer calibration. MODEL REQUIRED. Weight capacity: 400 lbs. Find more specifications at pridemobility.com/victory-10-3-wheel or pridemobility.com/victory-10-4-wheel. Victory 10 3-Wheel.......................................................... $2,669 Part: SC610. HCPCS: K0801 — Heavy Duty/Group 1. Victory 10 4-Wheel.......................................................... $2,819 Part: SC710. HCPCS: K0801 — Heavy Duty/Group 1. Standard Features • Two U-1 batteries • 3.5-amp off-board charger • Front basket • Foldable seat with sliders (18″W × 17″D) OPTIONAL SEATING The Victory 10 comes standard with a foldable 18″W × 17″D seat with sliders. Another seat type may be selected below or on Page 2. Deluxe Contour, 18″W × 18″D, no Sliders ........................ $600 Part: SETASMB2156 Deluxe Contour, 18″W × 20″D, no Sliders........................ $600 Part: SETASMB2375 Deluxe Contour, 20″W × 20″D, no Sliders ....................... $600 Part: SETASMB2168 Deluxe Contour, 22″W × 20″D, no Sliders........................ $600 Part: SETASMB2382 This form is interactive when viewed in Adobe Acrobat Reader and may not function correctly if opened with other applications. 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 Service for accurate parts ordering. Thank you for choosing Pride Mobility Products! INTRODUCTION Deluxe Contour, High Back, Black Vinyl Candy Apple Red SC610 part: SHDASMB5258 SC710 part: SHDASMB5246 Viper Blue SC610 part: SHDASMB5261 SC710 part: SHDASMB5253
Transcript of Victory 10 Order Form - Pride Mobility · 2020-02-21 · Victory® 10 Order Form — 3-Wheel and...
Page 1 of 3INFINFB3737/RevE/03FEB2020
Victory® 10 Order Form — 3-Wheel and 4-Wheel Scooters
Pride® Mobility Products Corporation182 Susquehanna Ave., Exeter, PA 18643Phone: 1-800-800-8586 | Fax: 1-800-800-1636 | Email: [email protected]
Account Number: ___________ Date: ________________
Provider Name: __________________________________
Contact: ________________________________________
Phone: ___________________ Fax: _________________
Email: __________________________________________
PO Number: _____________________________________
Marked for: _____________________________________
Ship to Address: _________________________________
City: _____________________ State: ______ Zip: ______
COLORREQUIRED. Colors shown here may differ from actual product depending on monitor/printer calibration.
MODELREQUIRED. Weight capacity: 400 lbs. Find more specifications at pridemobility.com/victory-10-3-wheel or pridemobility.com/victory-10-4-wheel.
Victory 10 3-Wheel. ......................................................... $2,669Part: SC610. HCPCS: K0801 — Heavy Duty/Group 1.
Victory 10 4-Wheel.......................................................... $2,819Part: SC710. HCPCS: K0801 — Heavy Duty/Group 1.
Standard Features• Two U-1 batteries• 3.5-amp off-board charger• Front basket• Foldable seat with sliders (18″W × 17″D)
OPTIONAL SEATINGThe Victory 10 comes standard with a foldable 18″W × 17″D seat with sliders. Another seat type may be selected below or on Page 2.
Deluxe Contour, 18″W × 18″D, no Sliders ........................ $600Part: SETASMB2156
Deluxe Contour, 18″W × 20″D, no Sliders ........................ $600Part: SETASMB2375
Deluxe Contour, 20″W × 20″D, no Sliders ....................... $600Part: SETASMB2168
Deluxe Contour, 22″W × 20″D, no Sliders........................ $600Part: SETASMB2382
This form is interactive when viewed in Adobe Acrobat Reader and may not function correctly if opened with other applications. 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 Service for accurate parts ordering.
Thank you for choosing Pride Mobility Products!
INTRODUCTION
Deluxe Contour, High Back, Black Vinyl
Candy Apple RedSC610 part: SHDASMB5258SC710 part: SHDASMB5246
Viper BlueSC610 part: SHDASMB5261SC710 part: SHDASMB5253
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Account Number: ___________ Date: ________________ Marked for: _____________________________________
CANE/CRUTCH HOLDEROptional. Only one cane/crutch holder can be used at a time.
LAP BELTSOptional.
50″ Lap Belt ...............................$39.90 Part: ACCBELT1000
60″ Lap Belt ...............................$39.90 Part: ACCBELT1002
70″ Lap Belt ................................$39.90 Part: ACCBELT1003
Rear Basket (15.25″ × 9.75″ ×9.5″) .. $80 Part: ACCBSKT1010
Oxygen Tank Holder ...................... $98Part: ACCASMB1017
Walker Holder ................................. $98Part: ACCASMB1018
ACCESSORIESOptional.
Wishbone Crutch Holder .................................................... $98Part: FRMASMB2358
Quad Cane Holder ............................................................... $98Part: ACCASMB1931
Forearm Crutch Holder ....................................................... $98Part: ACCASMB1019
Single Rear Mount, 3″...........................................................$70Part: ACCINDV1058
Double Rear Mount, 3″ .........................................................$70Part: ACCINDV1019
Cane Clip Attachment (Quantity of 2 Required) .......... $8 ea.For standard foldable seat only Part: ACCINDV1074
Medium Black Weather Cover .... $158Part: ACCCOVR1019
Large Black Weather Cover ........ $202Part: ACCCOVR1018
Cell Phone Holder .......................... $70Part: ACC145549
Rearview Mirror .............................. $25Part: LGTRMIR1003
Saddle Bag (12.5″ × 9.875″) ............ $35Part: DWR1020D010
Safety Flag ...................................... $38Part: ACCASMB2079
Cup Holder, Style B ....................... $20Used on SET151622 and all Deluxe Contour SeatsPart: ACCASMB2287
Cup Holder, Style C ....................... $20Used on Foldable SeatsPart: ACCASMB2288
Cup Holder, Style D ....................... $20Used on SET147133 Seat onlyPart: ACC120041
XLR USB Charger .......................... $38Part: ACC1704791
BACK-MOUNTED ACCESSORIESOptional. Only one back-mounted accessory can be used at a time. Includes mounting bracket and hardware.
BATTERIESThe Victory 10 comes standard with U-1 batteries. Another battery type may be selected below.
40Ah Batteries .................................................................................................................................................................................$350 ea. Part: BATLIQ1002Includes a 5-amp off-board charger
OPTIONAL SEATING ContinuedThe Victory 10 comes standard with a foldable 18″W × 17″D seat with sliders. Another seat type may be selected below or on Page 1.
Black Vinyl, High Back, no Sliders, 20″W × 20″D ..............................................................................................................................$300Part: SET1800951
High Back, Black Vinyl
Limited Recline, High Back with Sliders, 18″W × 18″D .. $300Part: SET147133
Limited Recline, High Back, no Sliders, 22″W × 18″D ... $350Part: SET151622
Limited Recline, High Back, Black Vinyl
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Pride® Mobility Products Corporation182 Susquehanna Ave., Exeter, PA 18643Phone: 1-800-800-8586 | Fax: 1-800-800-1636 | Email: [email protected]
COMMENTS
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
© 2020 Pride Mobility Products Corp. All rights reserved.
Account Number: ___________ Date: ________________ Marked for: _____________________________________
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