Victory 9 Order Form - Pride Mobility Products Corp. · Victory® 9 Quick Ship Order Form —...
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Page 1 of 2 INFINFB3724/RevD/09OCT2020 Victory ® 9 Quick Ship Order Form — 3-Wheel and 4-Wheel Scooters Pride ® Mobility Products Corporation 401 York Avenue, Duryea, PA 18642 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: ______ High Back, Deluxe Contour, 18″W × 18″D........................ $600 Part: SET134626 High Back, Deluxe Contour, 18″W × 20″D ....................... $600 Part: SET134627 OPTIONAL SEATING Select one seat. COLOR REQUIRED. Colors shown here may differ from actual product depending on monitor/printer calibration. Large Black Weather Cover........ $202 Part: ACCCOVR1018 Medium Black Weather Cover.... $158 Part: ACCCOVR1019 Cell Phone Holder .......................... $70 Part: ACC145549 Rearview Mirror.............................. $25 Part: LGTRMIR1003 Saddle Bag (12.5″ × 9.875″) ............ $35 Part: DWR1020D010 Cup Holder, Style B ....................... $20 Used on Deluxe Contour Seat Part: ACCASMB2287 Cup Holder, Style C ....................... $20 Used on Standard Foldable Seat Part: ACCASMB2288 Safety Flag ...................................... $38 Part: ACCASMB2079 XLR USB Charger .......................... $38 Part: ACC1704791 ACCESSORIES Optional. See Page 2 for back-mounted accessories. MODEL REQUIRED. Weight capacity: 300 lbs. Find more specifications at pridemobility.com/victory-9-3-wheel or pridemobility.com/victory-9-4-wheel. Victory 9 3-Wheel............................................................ $2,259 Part: SC609. HCPCS: K0800, Standard/Group 1 Victory 9 4-Wheel............................................................ $2,419 Part: SC709. HCPCS: K0800, Standard/Group 1 Standard Features • Two U-1 batteries • 3.5-amp off-board charger • Front basket • Foldable seat with sliders (18″W × 17″D) • LED headlight 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 config- ured as a complete scooter. Pride Providers may contact Technical Services for accurate parts ordering. Thank you for choosing Pride Mobility Products! INTRODUCTION FDA Class II Medical Devices* Candy Apple Red 3-Wheel SC609 part: SHDASMB5308 Candy Apple Red 4-Wheel SC709 part: SHDASMB5338
Transcript of Victory 9 Order Form - Pride Mobility Products Corp. · Victory® 9 Quick Ship Order Form —...
Page 1 of 2INFINFB3724/RevD/09OCT2020
Victory® 9 Quick Ship Order Form — 3-Wheel and 4-Wheel Scooters
Pride® Mobility Products Corporation401 York Avenue, Duryea, PA 18642Phone: 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: ______
High Back, Deluxe Contour, 18″W × 18″D ........................ $600Part: SET134626
High Back, Deluxe Contour, 18″W × 20″D ....................... $600Part: SET134627
OPTIONAL SEATINGSelect one seat.
COLORREQUIRED. Colors shown here may differ from actual product depending on monitor/printer calibration.
Large Black Weather Cover ........ $202Part: ACCCOVR1018
Medium Black Weather Cover .... $158Part: ACCCOVR1019
Cell Phone Holder .......................... $70Part: ACC145549
Rearview Mirror .............................. $25Part: LGTRMIR1003
Saddle Bag (12.5″ × 9.875″) ............ $35Part: DWR1020D010
Cup Holder, Style B ....................... $20 Used on Deluxe Contour SeatPart: ACCASMB2287
Cup Holder, Style C ....................... $20 Used on Standard Foldable SeatPart: ACCASMB2288
Safety Flag ...................................... $38Part: ACCASMB2079
XLR USB Charger .......................... $38Part: ACC1704791
ACCESSORIESOptional. See Page 2 for back-mounted accessories.
MODELREQUIRED. Weight capacity: 300 lbs. Find more specifications at pridemobility.com/victory-9-3-wheel or pridemobility.com/victory-9-4-wheel.
Victory 9 3-Wheel............................................................ $2,259Part: SC609. HCPCS: K0800, Standard/Group 1
Victory 9 4-Wheel............................................................ $2,419Part: SC709. HCPCS: K0800, Standard/Group 1
Standard Features• Two U-1 batteries• 3.5-amp off-board charger• Front basket
• Foldable seat with sliders (18″W × 17″D)
• LED headlight
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 config-ured as a complete scooter. Pride Providers may contact Technical Services for accurate parts ordering.
Thank you for choosing Pride Mobility Products!
INTRODUCTION
FDA Class II Medical Devices*
Candy Apple Red 3-WheelSC609 part: SHDASMB5308
Candy Apple Red 4-WheelSC709 part: SHDASMB5338
Page 2 of 2INFINFB3724/RevD/09OCT2020
Pride® Mobility Products Corporation401 York Avenue, Duryea, PA 18642Phone: 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.
CANE/CRUTCH HOLDEROptional. Only one cane/crutch holder can be used at a time.
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.Used on Standard Foldable Molded Plastic Seats with SlidersPart: ACCINDV1074
LAP BELTSOptional.
50″ Lap Belt ...............................$39.90 Part: ACCBELT1000
60″ Lap Belt ...............................$39.90 Part: ACCBELT1002
70″ Lap Belt ................................$39.90 Part: ACCBELT1003
Optional. Only one back-mounted accessory can be used at a time. Includes mounting bracket and hardware.
Rear Basket (15.25″ × 9.75″ × 9.5″) .. $80 Part: ACCBSKT1010
Oxygen Tank Holder ...................... $98Part: ACCASMB1017
Walker Holder ................................. $98Part: ACCASMB1018
BACK-MOUNTED ACCESSORIES
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facebook.com/PrideMobilityProductsCorp
twitter.com/pridemobility
instagram.com/PrideMobilityProducts
*Pride® Scooters are FDA Class II Medical Devices designed to aid individuals with mobility impairments.
