Page 1 of 2INFINFB3706/RevD/09OCT2017
Pursuit® - 4 Wheel PMV Scooter, Quick Ship, Order Form
Pride® Mobility Products Corporation182 Susquehanna Ave Exeter, PA 18643Phone: 800-800-8586 | Fax: 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 used.
Candy Apple RedPart: SHDASMB5804
SilverPart: SHDASMB5806
MODELREQUIRED. 400 lb. weight capacity. More details and specifications at found at pridemobility.com/scooters.
Pursuit. ...............................................................................................................................................................................................$4,299Part: SC713. HCPCS: K0899, Power mobility device, not coded by DME PDAC or does not meet criteria.
Includes standard options:• Black Vinyl, Reclining, High-Back Seat with sliders (18"W x 18"D)• Flat-free Tires• 5-AMP Off-board Charger• Full Light Package
NF-22, 55 AH, AGM. ................................................... StandardPart: BATLIQ1018
Group-24, 75 AH, AGM ................................................ $352 ea.Part: BATLIQ1019
BATTERIESREQUIRED. Requires two batteries.
4-Wheel, Black, Weather Cover ....................................... $202Part: ACCCOVR1018
Saddle Bag (12.5" x 9.875") ................................................ $35Part: DWR1020D010
Safety Flag ............................................................................ $38Part: ACCASMB2490
Throttle Pot Reversal ..........................................................$140Part: PTOINDV3601
Cup Holder, Style-D ............................................................. $20Part: ACC120041
Rear View Mirror .................................................................. $25Part: LGTRMIR1003
Cell Phone Holder .................................................................$70Part: ACC145549
Rear Basket (15.25" x 9.75" x 9.5") .................................... $80 Part: ACCBSKT1010
50" Lap Belt ..................................................................... $39.90 Part: ACCBELT1000
ACCESSORIESOptional.
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 ap-propriate 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. Please contact technical service for accurate parts ordering.
Thank you for choosing Pride Mobility Products!
INTRODUCTION
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 2INFINFB3706/RevD/09OCT2017
Pride® Mobility Products Corporation182 Susquehanna Ave Exeter, PA 18643Phone: 800-800-8586 | Fax: 800-800-1636 | Email: [email protected]
Mobility Made Easy. Pride offers a variety of lifts to transport your mobility product with ease. To find a compatible lift for your vehicle and mobility product, use our new Lift Finder applica-tion at pridemobility.com/lift-finder
Account Number: ___________ Date: ________________ Marked for: _____________________________________
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
© 2017 Pride Mobility Products Corp. All rights reserved.
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