Page 1 of 2 INFINFB3701/RevE/01OCT2017 Victory ® 10 LX - 4 Wheel Scooter, Quick Ship Order Form Pride ® Mobility Products Corporation 182 Susquehanna Ave Exeter, PA 18643 Phone: 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: ______ Black Vinyl, High Back, 18"W x 18"D. ..................... Standard With Sliders Part: SET147133 Black Vinyl, High Back, 22"W x 18"D............................. $350 Without Sliders Part: SET151622 SEATING REQUIRED. Select one seat. COLOR REQUIRED. Colors shown here may differ from actual product depending on monitor/printer calibration used. Candy Apple Red Part: DGN154334 True Blue Part: DGN154333 MODEL REQUIRED. 400 lb. weight capacity. More details and specifications at found at pridemobility.com/scooters. Victory 10 LX with CTS Suspension. ............................................................................................................................................. $2,899 Part: S710LX. HCPCS: K0899, Power mobility device, not coded by DME PDAC or does not meets criteria Includes standard options: • Two 40 Ah AGM batteries • 5-AMP Off-board charger • Light Package • Front Basket • Rear View Mirror ACCESSORIES Optional. 4-Wheel, Black, Weather Cover ....................................... $202 Part: ACCCOVR1018 Saddle Bag (12.5" x 9.875") ................................................ $35 Part: DWR1020D010 Safety Flag ............................................................................ $38 Part: ACCASMB2079 Cup Holder, Style-B (Used on 22" W Seats)..................... $20 Part: ACCASMB2287 Cup Holder, Style-D (Used on 18" W Seats)..................... $20 Part: ACC120041 Rear View Mirror .................................................................. $25 Part: LGTRMIR1003 Cell Phone Holder .................................................................$70 Part: ACC145549 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. Please contact technical service for accurate parts ordering. Thank you for choosing Pride Mobility Products! INTRODUCTION