Page 1 of 2 INFINFB3724/RevD/09OCT2020 Victory ® 9 Quick Ship Order Form — 3-Wheel and 4-Wheel Scooters 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: ______ High Back, Deluxe Contour, 18″W × 18″D........................ $600 Part: SET134626 High Back, Deluxe Contour, 18″W × 20″D ....................... $600 Part: SET134627 OPTIONAL SEATING Select one seat. COLOR REQUIRED. Colors shown here may differ from actual product depending on monitor/printer calibration. Large Black Weather Cover........ $202 Part: ACCCOVR1018 Medium Black Weather Cover.... $158 Part: ACCCOVR1019 Cell Phone Holder .......................... $70 Part: ACC145549 Rearview Mirror.............................. $25 Part: LGTRMIR1003 Saddle Bag (12.5″ × 9.875″) ............ $35 Part: DWR1020D010 Cup Holder, Style B ....................... $20 Used on Deluxe Contour Seat Part: ACCASMB2287 Cup Holder, Style C ....................... $20 Used on Standard Foldable Seat Part: ACCASMB2288 Safety Flag ...................................... $38 Part: ACCASMB2079 XLR USB Charger .......................... $38 Part: ACC1704791 ACCESSORIES Optional. See Page 2 for back-mounted accessories. MODEL REQUIRED. Weight capacity: 300 lbs. Find more specifications at pridemobility.com/victory-9-3-wheel or pridemobility.com/victory-9-4-wheel. Victory 9 3-Wheel............................................................ $2,259 Part: SC609. HCPCS: K0800, Standard/Group 1 Victory 9 4-Wheel............................................................ $2,419 Part: SC709. HCPCS: K0800, Standard/Group 1 Standard Features • Two U-1 batteries • 3.5-amp off-board charger • Front basket • Foldable seat with sliders (18″W × 17″D) • LED headlight 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 config- ured as a complete scooter. Pride Providers may contact Technical Services for accurate parts ordering. Thank you for choosing Pride Mobility Products! INTRODUCTION FDA Class II Medical Devices* Candy Apple Red 3-Wheel SC609 part: SHDASMB5308 Candy Apple Red 4-Wheel SC709 part: SHDASMB5338