Maxima 3-Wheel and 4-Wheel Scooter Order Form€¦ · INFINFB37RevD03FEB00 Page 1 of 3 Maxima®...
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Page 1 of 3 INFINFB3728/RevD/03FEB2020 Maxima ® Order Form — 3-Wheel and 4-Wheel Scooter Pride ® Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA 18643 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: ______ COLOR REQUIRED. Colors shown here may differ from actual product depending on monitor/printer calibration. Candy Apple Red 3-Wheel Part: DGN144625 4-Wheel Part: DGN133697 Viper Blue 3-Wheel Part: DGN144626 4-Wheel Part: DGN136707 MODEL REQUIRED. Weight capacity: 500 lbs. Find more specifications at pridemobility.com/maxima-3-wheel and pridemobility.com/maxima-4-wheel. Maxima 3-Wheel............................................................. $4,099 Part: SC900. HCPCS: K0802, Group 1-Very Heavy Duty Maxima 4-Wheel............................................................. $4,499 Part: SC940. HCPCS: K0808, Group 2-Very Heavy Duty Standard Features • Two 55Ah AGM NF-22 batteries • 5-amp off-board charger • Front basket • 22 ″ × 18 ″ medium-back seat • Light package • Rearview mirror Power Elevating Seat ........................................................................................................................................................................ $1,100 Part: MEC144637 POWER ELEVATING SEAT Optional. Only available with the Maxima 3-wheel. Requires U-1 batteries (see below). BATTERIES REQUIRED. The Maxima requires two batteries. NF-22............................................................................ Standard Part: BATASMB1004 Not available with Power Elevating Seat U-1 .................................................................................. $133 ea. Part: BAT120002 Required with Power Elevating Seat 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 Service for accurate parts ordering. Thank you for choosing Pride ® Mobility Products! INTRODUCTION
Transcript of Maxima 3-Wheel and 4-Wheel Scooter Order Form€¦ · INFINFB37RevD03FEB00 Page 1 of 3 Maxima®...
Page 1 of 3INFINFB3728/RevD/03FEB2020
Maxima® Order Form — 3-Wheel and 4-Wheel Scooter
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: ______
COLORREQUIRED. Colors shown here may differ from actual product depending on monitor/printer calibration.
Candy Apple Red3-Wheel Part: DGN1446254-Wheel Part: DGN133697
Viper Blue3-Wheel Part: DGN1446264-Wheel Part: DGN136707
MODELREQUIRED. Weight capacity: 500 lbs. Find more specifications at pridemobility.com/maxima-3-wheel and pridemobility.com/maxima-4-wheel.
Maxima 3-Wheel ............................................................. $4,099Part: SC900. HCPCS: K0802, Group 1-Very Heavy Duty
Maxima 4-Wheel ............................................................. $4,499Part: SC940. HCPCS: K0808, Group 2-Very Heavy Duty
Standard Features• Two 55Ah AGM NF-22 batteries• 5-amp off-board charger• Front basket
• 22″ × 18″ medium-back seat• Light package• Rearview mirror
Power Elevating Seat ........................................................................................................................................................................$1,100Part: MEC144637
POWER ELEVATING SEATOptional. Only available with the Maxima 3-wheel. Requires U-1 batteries (see below).
BATTERIESREQUIRED. The Maxima requires two batteries.
NF-22 ............................................................................ StandardPart: BATASMB1004Not available with Power Elevating Seat
U-1 .................................................................................. $133 ea.Part: BAT120002Required with Power Elevating Seat
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 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
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Account Number: ___________ Date: ________________ Marked for: _____________________________________
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
ACCESSORIESOptional.
Medium Black Weather Cover ......$158Part: ACCCOVR1019
Large Black Weather Cover..........$202Part: ACCCOVR1018
Cane Clip ......................................... $51Part: ACCASMB1980
Cup Holder, Style B........................ $20Part: ACCASMB2287
Saddle Bag (12.5″ × 9.875″) ............ $35Part: DWR1020D010
Safety Flag ...................................... $38Part: ACCASMB1907
Rearview Mirror (additional)......... $25Part: ACC134496
XLR USB Charger .......................... $38Part: ACC1704791
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.
LAP BELTSOptional. Seats come with a 60″ lap belt. Another lap belt size may be selected below.
50″ Lap Belt ...............................$39.90 Part: ACCBELT1000
70″ Lap Belt ................................$39.90 Part: ACCBELT1003
80″ Lap Belt ...............................$39.90 Part: ACCBELT1004
90″ Lap Belt ...............................$39.90 Part: ACCBELT1001
SEATINGOptional. The Maxima comes standard with a 22″W × 18″D medium-back seat. Other seats may be selected below. Sliders not available on any Maxima seating.
Deluxe Contour, Medium-Back
18″W × 18″D ................................... $600Part: SET134626
22″W × 18″D ................................... $600Part: SET134630
22″W × 20″D ................................... $600Part: SET134631
Deluxe Contour, High-Back
20″ W × 18″D ................................... $150Part: SET134621
22″W × 20″D ................................... $150Part: SET134624
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
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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
