victory lx sport order form - pride mobility products corp. · 2020-02-21 · part: s710lxw. hcpcs:...
TRANSCRIPT
Page 1 of 2INFINFB3823/RevA/03FEB2020
Victory® LX Sport 4-Wheel Scooter Quick Ship Order Form
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: ______
18″W × 18″D ........................... StandardWith Sliders Part: SET147133
20″W × 20″D ................................... $300No SlidersPart: SET1800951
22″W × 18″D ................................... $350No SlidersPart: SET151622
SEATING — LIMITED RECLINE, HIGH BACK, BLACK VINYLREQUIRED. Select one seat.
COLORREQUIRED. Colors shown here may differ from actual product depending on monitor/printer calibration.
Candy Apple RedPart: DGN138560
True BluePart: DGN143071
ACCESSORIESOptional.
Large Weather Cover ................... $202Part: ACCCOVR1018
Saddle Bag (12.5″ × 9.875″) ........... $35Part: DWR1020D010
Safety Flag ...................................... $38Part: ACCASMB2079
Cup Holder, Style B ....................... $20Used on SET1800951 and SET1515622 seatsPart: ACCASMB2287
Cup Holder, Style D ....................... $20Used on SET147133 seatPart: ACC120041
Rearview Mirror (Additional) ........ $25Part: LGTRMIR1003
Cell Phone Holder .......................... $70Part: ACC1804467
USB Charger Port .......................... $38Part: ACC1704791
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
MODELREQUIRED. Weight capacity: 400 lbs. Find more details and specifications at pridemobility.com/victory-lx-sport-4-wheel.
Victory LX Sport with CTS Suspension ......................$3,359Part: S710LXW. HCPCS: K0899, Power mobility device, not coded by DME PDAC or does not meet criteria.
Standard Features• CTS suspension• Low/high speed control• Two 50Ah AGM batteries• 5-amp off-board charger
• Full light package• Front basket• One rearview mirror• Delta tiller
Page 2 of 2INFINFB3823/RevA/03FEB2020
Pride® Mobility Products Corporation182 Susquehanna Ave., Exeter, PA 18643Phone: 1-800-800-8586 | Fax: 1-800-800-1636 | Email: [email protected]
Account Number: ___________ Date: ________________ Marked for: _____________________________________
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
Single Rear Mount, 3″...........................................................$70Part: ACCINDV1058
Double Rear Mount, 3″ .........................................................$70Part: ACCINDV1019
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
BACK-MOUNTED ACCESSORIESOptional. Only one back-mounted accessory can be used at a time. Includes mounting bracket and hardware.
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