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Page 1 of 2 INFINFB4219/RevA/30JUL2021 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: ______ Go Chair ® MED Quick Ship Order Form MODEL REQUIRED. Weight capacity: 300 lbs. Find more details and specifications at pridemobility.com/go-chair-med. Go Chair MED, Black........................................................$3,489 Part: GOCHAIRMED. HCPCS: K0821 Standard Features • Controller (GC3) • Joystick mounting bracket (fixed in-line) • Foot platform • Lap belt, 60 ″ • 2-amp off-board charger 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. Pride Providers may contact Technical Services for accurate parts ordering. Thank you for choosing Pride Mobility Products! INTRODUCTION BATTERY BOX SELECTION REQUIRED. The power chair requires two batteries. The batteries are automatically selected with a Quick Ship order. SEATING REQUIRED. Select a seat below. Seats include a 60″ lap belt. ARMRESTS — HEIGHT-ADJUSTABLE, WIDTH-ADJUSTABLE, REMOVABLE REQUIRED. The armrests are automatically selected with a quick ship order. JOYSTICK MOUNTING BRACKET Optional. 18Ah Battery ......................................................................................................................................................................................$40 ea. Part: BATLIQ1000. HCPCS: K0733 Foldable Seat, 18″ × 17″ ............................................. Standard Part: SET1902335 Foldable Seat, 20″ × 18″ ............................................. Standard Part: SET1902334 Armrest, Left .................................................................. $85 ea. Part: ARM151657. HCPCS: E0973 Armrest, Right ................................................................ $85 ea. Part: ARM151658. HCPCS: E0973 Swing-Away In-line Joystick Mounting Bracket, Left ... $245 Part: KIT1906945. HCPCS: E1028 Swing-Away In-line Joystick Mounting Bracket, Right ..$245 Part: KIT1905628. HCPCS: E1028 ® FDA Class II Medical Device*

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Page 1: Go Chair® MED Order Form - Pride Mobility Products Corp. · 2020. 10. 20. · Title: Go Chair® MED Order Form Subject: Go Chair MED Order Form with Quick Ship options only. Created

Page 1 of 2INFINFB4219/RevA/30JUL2021

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: ______

Go Chair® MED Quick Ship Order Form

MODELREQUIRED. Weight capacity: 300 lbs. Find more details and specifications at pridemobility.com/go-chair-med.

Go Chair MED, Black ........................................................$3,489Part: GOCHAIRMED. HCPCS: K0821

Standard Features• Controller (GC3)• Joystick mounting bracket

(fixed in-line)• Foot platform

• Lap belt, 60″• 2-amp off-board charger

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. Pride Providers may contact Technical Services for accurate parts ordering.

Thank you for choosing Pride Mobility Products!

INTRODUCTION

BATTERY BOX SELECTIONREQUIRED. The power chair requires two batteries. The batteries are automatically selected with a Quick Ship order.

SEATINGREQUIRED. Select a seat below. Seats include a 60″ lap belt.

ARMRESTS — HEIGHT-ADJUSTABLE, WIDTH-ADJUSTABLE, REMOVABLEREQUIRED. The armrests are automatically selected with a quick ship order.

JOYSTICK MOUNTING BRACKETOptional.

18Ah Battery ......................................................................................................................................................................................$40 ea.Part: BATLIQ1000. HCPCS: K0733

Foldable Seat, 18″ × 17″ ............................................. StandardPart: SET1902335

Foldable Seat, 20″ × 18″ ............................................. StandardPart: SET1902334

Armrest, Left .................................................................. $85 ea.Part: ARM151657. HCPCS: E0973

Armrest, Right ................................................................ $85 ea.Part: ARM151658. HCPCS: E0973

Swing-Away In-line Joystick Mounting Bracket, Left ... $245Part: KIT1906945. HCPCS: E1028

Swing-Away In-line Joystick Mounting Bracket, Right ..$245Part: KIT1905628. HCPCS: E1028

®

FDA Class II Medical Device*

https://www.pridemobility.com/jazzy-power-chairs/go-chair-med/
https://get.adobe.com/reader/
Page 2: Go Chair® MED Order Form - Pride Mobility Products Corp. · 2020. 10. 20. · Title: Go Chair® MED Order Form Subject: Go Chair MED Order Form with Quick Ship options only. Created

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

Page 2 of 2INFINFB4219/RevA/30JUL2021

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® Mobility Products Corporation401 York Avenue, Duryea, PA 18642Phone: 1-800-800-8586 | Fax: 1-800-800-1636 | Email: [email protected]

© 2021 Pride Mobility Products Corp. All rights reserved.

youtube.com/pridemobility

facebook.com/PrideMobilityProductsCorp

twitter.com/pridemobility

instagram.com/PrideMobilityProducts

NOTES

CANE/CRUTCH HOLDERSOptional. Only one cane/crutch holder can be used at a time.

Single Rear Mount, 3″...........................................................$70Part: ACCINDV1058. HCPCS: E2207

Double Rear Mount, 3″ .........................................................$70Part: ACCINDV1019. HCPCS: E2207

ACCESSORIESOptional.

Weather Cover, Micro .........................................................$140Part: ACCCOVR1023

50″ Additional Lap Belt .................................................. $39.90Part: ACCBELT1000

70″ Additional Lap Belt .................................................. $39.90Part: ACCBELT1003

Cup Holder, Style B ............................................................. $30Part: ACCASMB2287

Safety Flag ............................................................................ $38Part: ACCFLAG1000

Saddle Bag (12.5″ × 9.875″) ................................................. $40Part: DWR1020D010

Oxygen Tank Holder ............................................................ $98Part: ACCASMB1017. HCPCS: E2208

Additional 18Ah Battery Pack .......................................... $507Part: BAT155865

2.1A XLR USB Charger ................................................... $42.99Part: KIT2001524

*Pride® Power Chairs are FDA Class II Medical Devices designed to aid individuals with mobility impairments.

https://www.youtube.com/user/PrideMobility
https://www.facebook.com/PrideMobilityProductsCorp
https://www.twitter.com/PrideMobility
https://www.instagram.com/pridemobilityproducts/

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