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INFINFB3740/RevB/03FEB2020
Pride
®
Mobility Products Corporation
182 Susquehanna Ave., Exeter, PA 18643
Phone: 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: ______
Go-Go
®
Folding Scooter Order Form
ACCESSORIES
Optional.
Arm Rests (pair) ....................................................................................................................................................................................$159
Part: ARM150059
Weather Cover, Scooter, Micro ...........................................................................................................................................................$114
Part: ACCCOVR1020
MODEL
REQUIRED. Weight capacity: 250 lbs. Includes gray vinyl seat (16″W × 13″D) and at-free tires. More details and specications can be found at
pridemobility.com/go-go-folding-scooter-4-wheel.
Go-Go Folding Scooter, White, with Sealed Lead Acid Batteries ............................................................................................. $2,499
Includes two 12-volt batteries and a 2-amp o-board charger
Part: S19WH1001. HCPCS: K0899 — Power Mobility Device, not coded by DME PDAC or does not meet criteria.
Go-Go Folding Scooter, White, with Lithium-ion Battery ........................................................................................................... $2,949
Includes one 24-volt battery and a 2.5-amp o-board charger
Part: S19WH1002. HCPCS: K0899 — Power Mobility Device, not coded by DME PDAC or does not meet criteria.
BRANCH PATCHES
Optional.
Air Force Patch ............................... $20
Part: ACC140240
Army Patch ..................................... $20
Part: ACC140241
Coast Guard Patch ........................ $20
Part: ACC140239
Marines Patch ................................. $20
Part: ACC140243
Navy Patch ...................................... $20
Part: ACC140244
Purple Heart Patch ........................ $20
Part: ACC140238
© 2020 Pride Mobility Products Corp. All rights reserved.
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INTRODUCTION
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, specications, part numbers, and availability are subject to change without notice. Prices and part numbers as shown are only available
when congured as a complete scooter. Pride Providers may contact Technical Services for accurate parts ordering.
Thank you for choosing Pride Mobility Products!