jazzy 614hd configurable order form · armrests. 14" and 15" back canes are not available...

of 10INFINFB4024/RevA/07SEP2018

Jazzy® 614 HD Configurable Order FormAccount Number: ___________ Date: ________________

Provider Name: __________________________________

Contact: ________________________________________

Phone: ___________________ Fax: _________________

Email: __________________________________________

PO Number: _____________________________________

Marked for: _____________________________________

Ship to Address: _________________________________

City: _____________________ State: ______ Zip: ______

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 power chair. Please contact technical service for accurate parts ordering.

Thank you for choosing Pride Mobility Products!

INTRODUCTION

Candy Apple RedPart: SHDASMB5335

Viper BluePart: SHDASMB5336

BASE COLORREQUIRED. Select one shroud color. Colors shown here may differ from actual product depending on monitor/printer calibration used.

Jazzy 614HD 2HD-C ........................................................$5,299Part: J614HD 2HD-C. HCPCS: K0825Captain Seating

Jazzy 614HD 2HD-SS......................................................$5,299Part: J614HD 2HD-SS. HCPCS: K0824Solid Seat Pan Seating

BASE MODELREQUIRED. Select a power base. 450 lb. weight capacity and includes Shark joystick and 4 amp off-board charger. More details and specifica-tions can be found at pridemobility.com/jazzy_power_Chairs.

Pride® Mobility Products Corporation182 Susquehanna Ave Exeter, PA 18643Phone: 800-800-8586 | Fax: 800-800-1636 | Email: [email protected]

JOYSTICK MOUNTING BRACKETSREQUIRED.

Omit Joystick Mounting Bracket

Swing Away JoystickInline Mount (Right)

Swing Away JoystickOffset Mount (Right)

Fixed, In-line, Bracket ......................................................................................................................... StandardPart: FRMASMB11349

Left Side MountPart: PTOINDV1225

Right Side MountPart: PTOINDV1226

Swing-away, Inline, Left Side Mount ............$245Part: ACC142532. HCPCS: E1028

Swing-away, Inline, Right Side Mount .........$245Part: ACC142533. HCPCS: E1028

Swing-away, 1” Offset, Left Side Mount ......$245Part: ACC142751. HCPCS: E1028

Swing-away, 1” Offset, Right Side Mount ...$245Part: ACC142752. HCPCS: E1028

Swing-Away (Retractable) BracketAllows the joystick to retract to the side of the armrest while maintaining the same joystick orientation. "Inline brack-et" will be offset 1" when used with tube style arms. Select "Offset Bracket" to have the joystick inline with armpad on tube style armrests.

Fixed, In-line Joystick Bracket

Base Mounted Foot Platform ................................... StandardPart: FRMASMB13998

Omit base mounted foot platform .........................No ChargePart: PTOINDV3674

BASE MOUNTED FOOT PLATFORMREQUIRED. Select a foot platform option. May interfere with seat mounted legrests. Not available with center mount foot platforms.

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Account Number: ___________ Date: ________________ Marked for: _____________________________________

Deluxe Contour, Limited Recline, High Back with Solid Seat Pan

Solid Seat Pan Seating

JOYSTICK HANDLESOptional. The shark joystick includes a carrot style joystick handle as shown in the power chair image on page 1.

DL Knob .......................................... $35Part: ACCASMB1865. HCPCS: E2323

Wrist Plate ....................................... $45Part: ACCASMB1868. HCPCS: E2323

Round T-Bar .................................... $45Part: ACCASMB1869. HCPCS: E2323

Flat T-Bar ......................................... $45Part: ACCASMB1870. HCPCS: E2323

Straight Bar ..................................... $45Part: ACCASMB1871. HCPCS: E2323

Finger Tube ..................................... $45Part: ACCASMB1872. HCPCS: E2323

PROGRAMMEROptional.

Dynamic Programmer with Flight Adapter .......................................................................................................................................$423Part: ELEASMB4352

CONTOURED SEATINGOptional. Select only one seat with size. Seats come with a lap belt. Maximum weight capacity is 400 lbs. when seat is set at 18”D.

18”Wx18”-20”D ..................... StandardPart: SETASMB6895With 60" Lap Belt

20”Wx18”-20”D ..................... StandardPart: SETASMB6896With 60" Lap Belt

22”Wx20”-22”D .................... StandardPart: SETASMB6897With 70" Lap Belt

Depth-Adjustable, Fold Flat, Limited Recline, High Back

Deluxe Contour, Limited Recline, High Back

Deluxe Contour, High Back

Captain Seating

16”Wx16”D ....................................$450Part: SETASMB2770

16”Wx18”D ....................................$450Part: SETASMB2771

16”Wx20”D....................................$450Part: SETASMB2772

16”Wx22”D....................................$450Part: SETASMB4887

18”Wx16”D ....................................$450Part: SETASMB2775

18”Wx22”D....................................$450Part: SETASMB4888

20”Wx16”D ....................................$450Part: SETASMB2780

20”Wx22”D ................................ $1,000Part: SETASMB4889

20”Wx24”D ...................................$450Part: SETASMB2380

22”Wx18”D ....................................$450Part: SETASMB2171

22”Wx20”D ...................................$450Part: SETASMB2382

22”Wx22”D ...................................$450Part: SETASMB2383

22”Wx24”D ...................................$450Part: SETASMB2384

24”Wx18”D ....................................$450Part: SETASMB2386

24”Wx20”D ...................................$450Part: SETASMB2387

24”Wx22”D ................................ $1,000Part: SETASMB2388

24”Wx24”D ...................................$450Part: SETASMB2389

16”Wx16”D ....................................$450Part: SETASMB317816”Wx18”D ....................................$450Part: SETASMB317916”Wx20”D....................................$450Part: SETASMB318016”Wx22”D....................................$450Part: SETASMB5006

18”Wx16”D ....................................$450Part: SETASMB318118”Wx18”D ....................................$450Part: SETASMB284818”Wx20”D ............................ StandardPart: SETASMB318218”Wx22”D............................ StandardPart: SETASMB5007

20”Wx16”D ....................................$450Part: SETASMB318320”Wx18”D ............................ StandardPart: SETASMB318420”Wx20”D ........................... StandardPart: SETASMB318520”Wx22”D ........................... StandardPart: SETASMB5008



CONTOURED SEATING continuedDeluxe Contour, High Back with Solid Seat Pan

20”Wx24”D ........................... StandardPart: SETASMB2982

22”Wx18”D ....................................$450Part: SETASMB2984

22”Wx20”D ................................... $275Part: SETASMB2985

22”Wx22”D ...................................$450Part: SETASMB2986

22”Wx24”D ........................... StandardPart: SETASMB2987

24”Wx18”D ....................................$450Part: SETASMB2989

24”Wx20”D ................................... $275Part: SETASMB2990

24”Wx22”D ...................................$450Part: SETASMB2991

24”Wx24”D ................................... $275Part: SETASMB2992

SYNERGY SEATINGOptional.

Special Measurement Seat

Width:______ Depth:______ Seat Type:_______________

Synergy Seating Frame ........................................................................................................................................................................$434Part: PTOINDV2995

10”-14” Width PackagePart: FRMASMB12043




10” W(#1000)

11” W(#1001)

12” W(#1002)

13” W(#1003)

14” W(#1004)

15” W(#1005)

16” W(#1006)

17” W(#1007)

18” W(#1008)

19” W(#1009)

20” W(#1010)

21” W(#1011)

22” W(#1012)

23” W(#1013)

24” W(#1014)

Synergy Frame Selection

Seat Dimensions - WidthREQUIRED with Synergy seating. Part number is SETWDTH plus number following # below.

Seat Dimensions - DepthREQUIRED with Synergy seating. Part number is SETDPTH plus number following # below.

Seat Dimensions - Depth PackageREQUIRED with Synergy seating.

Seat Dimensions - Width PackageREQUIRED with Synergy seating.

Special Measurement SeatOptional. Special Order selections are not available as a Quick Ship order. Seat size can not exceed 24"W x 24"D. Contact your inside sales specialist for pricing.

Contoured Seat ArmrestsOptional for all seats except depth-adjustable contoured seats.

10”-14” Depth PackagePart: FRMASMB6981




10” D(#1000)

11” D(#1001)

12” D(#1002)

13” D(#1003)

14” D(#1004)

15” D(#1005)

16” D(#1006)

17” D(#1007)

18” D(#1008)

19” D(#1009)

20” D(#1010)

21” D(#1011)

22” D(#1012)

23” D(#1013)

24” D(#1014)

Flip-up, Height Adjustable, Full Length Armrests.................................................................................................................$85 ea.Left part: FRMASMB8614. Right part: FRMASMB8615. HCPCS: E0973



Synergy Back ......................................................................$275Part: See XRefSelect a back cane type and height and back height.

TRU-Comfort 4-way Stretch, 20” Width or less ............ $675Part: See XRef. HCPCS: E2620Select back height.

Sling Back ............................................................................. $98Part: See XRefSelect a back height. Available 18"-25" overall heights. Back cane height must match back height. Not available with flip up cantilever arms.

Omit Back .................................................................No ChargePart: PTOINDV1287Select a back cane type and height in following section.

Synergy Back Cane .................................................No ChargePart: FRMASMB15844Select a back cane height.

Flip Forward Back Cane .....................................................$150Part: FRMASMB15846Select a back cane height. Not available with a vent tray, oxygen holder, or cane mounted and cantilever armrests.

2” Mesomorph (1” per side) Back Cane ..........................$195Part: FRMASMB12067Select a cane height.

4” Mesomorph (2” per side) Back Cane ..........................$195Part: FRMASMB12091Select a cane height.

2” Endomorph (1” per side) Back Cane ...........................$195Part: FRMASMB12115Select a cane height.

4” Endomorph (2” per side) Back Cane...........................$195Part: FRMASMB12139Select a cane height.

Push Handles ............................................................. StandardPart: Configuration selection with back cane height

Omit Push Handles .............................................................$125Part: Configuration selection with back cane heightNot available with Sling Back. Minimum cane height is 16".

Accessory Bar .......................................................................................................................................................................................$10012"W-16"W Part: MEC145955. 16"W-20"W Part: MEC143975.

Synergy Back OptionsREQUIRED with Synergy seating. See the Synergy and TRU-Comfort back availability chart for stock order back size ranges. Other size backs may be available with special order and extended lead time.

SYNERGY SEATING continued

Back Selection

Back Cane Selection

Synergy Push Handles

Synergy Accessory Bar

Synergy Overall Back HeightRefer to the Synergy and TRU-Comfort back availability chart for stock order back size ranges. Parts: See XRef, configuration selection with back selection.

13” High

14” High

15” High

16” High

17” High

18” High

19” High

20” High

21” High

22” High

23” High

24” High

25” High

Width

Synergy and TRU-Comfort Back Availability Chart

Synergy Back Synergy or TRU-Comfort Back

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Synergy Back Cane HeightOmit this selection if a TRU-Comfort back is selected. 16" and 17" back canes are not available with a Synergy Back and cane mounted, flip up armrests. 14" and 15" back canes are not available without push handles. Parts: See XRef, configuration selection with push handles selection.

Flip Back, Cane Mounted ArmrestsMay interfere with swing-away laterals

Two-Post, Flip Back, Height Adjustable, Removable ArmrestsNot available with a depth less than 16". Required with flip forward back and laptrays.

Single-Post, Heavy Duty, 8"-12" Height Adjustable, Removable Armrests

Single-Post, Height Adjustable, Removable ArmrestsHeight adjustment from 11"-17" in half-inch increments.

Bariatric, Single-Post, Heavy Duty, Height Adjustable, Removable ArmrestsOnly available with bariatric armpads and in pairs (priced individually).

Single-Post, Heavy Duty, 10"-14" Height Adjustable, Removable Armrests

Height Adjustable, Cantilever ArmrestsHeight adjustment from 11"-17" depends on cane height. Not available with manual recline, flip forward back canes, or cane clamp pushbar.

14” High Canes

15” High Canes

16” High Canes

17” High Canes

18” High Canes

19” High Canes

20” High Canes

21” High Canes

22” High Canes

23” High Canes

24” High Canes

25” High Canes

SYNERGY SEATING continued

Synergy Back OptionsREQUIRED with Synergy seating. Left (L) and right (R) boxes may be checked to configure different size arms within one section arm type.

Synergy ArmpadsREQUIRED with Synergy seating. Waterfall armpads may cause interference with the seat back. Armpads are configured as pairs.

Full Length, Flip Back Armrests ........................ StandardLeft Part: FRMASMB7038. Right part: FRMASMB7039

Desk Length, Flip Back Armrests ...................... StandardLeft part: FRMASMB7040. Right part: FRMASMB7041

Full Length, Two-Post Armrests .......................... $150 ea.Left Part: FRMASMB7062. Right part: FRMASMB7063. HCPCS: E0973

Desk Length, Two-Post Armrests ........................ $150 ea.Left part: FRMASMB7060. Right part: FRMASMB7061. HCPCS: E0973

Full Length, Heavy Duty Armrests, 8"-12" H ........ $85 ea.Left part: FRMASMB9982. Right part: FRMASMB9983. HCPCS: E0973

Desk Length, Heavy Duty Armrests, 8"-12"H ...... $85 ea.Left part: FRMASMB9984. Right part: FRMASMB9985. HCPCS: E0973

Full Length, Heavy Duty Armrests, 10"-14"H ....... $85 ea.Left Part: FRMASMB9986. Right part: FRMASMB9987. HCPCS: E0973

Desk Length, Heavy Duty Armrests, 10"-14"H .... $85 ea.Left part: FRMASMB9988. Right part: FRMASMB9989. HCPCS: E0973

Full Length, Cantilever Armrests ...................... $97.50 ea.Left Part: FRMASMB16188. Right part: FRMASMB16189

Desk Length, Cantilever Armrests ................... $97.50 ea.Left part: FRMASMB16190. Right part: FRMASMB16191

Full Length, Single Post Armrests ......................... $75 ea.Left Part: FRMASMB8594. Right part: FRMASMB8595. HCPCS: E0973

Desk Length, Single Post Armrests ...................... $75 ea.Left part: FRMASMB8592. Right part: FRMASMB8593. HCPCS: E0973

Bariatric Armpads ...................................................No ChargePart: UPSASMB1025.Only available with Bariatric Armrests.

Straight Armpads ...................................................... StandardDesk/Desk part: UPSASMB1022. Full/Full part: UPSASMB1021.Desk/Full part: UPSASMB1023

Waterfall Armpads ...................................................No ChargeDesk/Desk part: UPSASMB1025. Full/Full part: UPSASMB1024. Desk/Full part: UPSASMB1026

No Armpad Selection .............................................No ChargePart: PTOINDV1373

Full Length, Bariatric Armrests, 8"-12" H ................... $85 ea.Left part: FRMASMB6728. Right part: FRMASMB6729. HCPCS: E0973

Full Length, Bariatric Armrests, 10"-14"H .................. $85 ea.Left part: FRMASMB6730. Right part: FRMASMB6731. HCPCS: E0973

Standard Fixed Receiver........................................... StandardPart: FRMASMB16062

Stealth Height Adjustable Receiver .................................$214Tube Arm Part: ST-ARM250C-Q, HCPCS: K0108

JOYSTICK BRACKET RECEIVERREQUIRED.



HEADREST PADSOptional. Not available with contoured seating.

Optional Lap BeltsNot available with contoured seating.

Headrest Pads

Headrest Bracket

LAP BELTSREQUIRED except with select contoured seats with included lap belt. Select one lap belt below.

50” Lap BeltPart: ACCBELT1000





i-Fit 60” Single Pull, Push Button, Medium ...................... $86(7.5”) Padded, 1.5” Belt (IFPB5213)Part: ST-IFPB5213-Q

i-Fit 60” Single Pull, Push Button, Large .......................... $86Padded (9.5”), 2” Belt (IFPB5314)Part: ST-IFPB5314-Q

i-Fit 60” Single Pull, Push Button, Extra Large ............... $86Padded (11.5”), 2” Belt (IFPB5315)Part: ST-IFPB5315-Q

Stealth’s Worlds Best Removable .............................. $220.50Headrest Bracket (TWB485-1) (C)Part: FRMASMB15999. HCPCS: E1028

Pediatric Offset (HMO475P-17) (E) .............................. $160.50Part: HDWASMB1166. HCPCS: E1028

Stealth Multi-Axis Removable (D) .............................. $160.50Headrest Bracket (HMO475P)Part: HDWASMB1084. HCPCS: E1028

Stealth 8” Comfort Plus (CP450) ............. $151.94Part: POS148484. HCPCS: E0955

Stealth 10” Comfort Plus (CP250) (A) ..... $151.94Part: SETHEAD1057. HCPCS: E0955

Stealth 14” Comfort Plus (CP150) ............ $151.94Part: INDPART2327. HCPCS: E0955

Pediatric Comfort Plus (6”Wx4.5”H) ....... $151.94(CPN350)Part: SETHEAD1069. HCPCS: E0955

Stealth Small Contoured (9.75”Wx3”H) ....$64.20(STL-OTSM250)Part: SETHEAD1052. HCPCS: E0955

Stealth Large Contoured (11”Wx6”H) (B) .$80.25(STL-OTLG150)Part: SETHEAD1053. HCPCS: E0955

Headrests

LEGRESTS

70° HD Drop-in with 12"-14.5" ....................No Charge Length Lower Extension

Pair part: FRMASMB4762. Left: RIG137706. Right: RIG137707

70° HD Drop-in with 14.5-18" ......................No Charge Length Lower Extension

Pair part: FRMASMB4853. Left: RIG137708. Right: RIG137709

6”Wx8”D1 ............................................................. $85 ea.Pair part: FRMASMB4738. Left: RIG137793. Right: RIG137795.

6”Wx11”D1 ............................................................ $85 ea.Pair part: FRMASMB4741. Left: RIG137796. Right: RIG137797.May cause interference on seat widths less than 18".

8”Wx11”D2 ............................................................ $85 ea.Pair part: FRMASMB4744. Left: RIG137708. Right: RIG137709.May cause interference on seat widths less than 20".

Wheel Bumper(s) .............................................................................................................................................................$12.50 ea.Pair part: WHLASMB1578. Left part: WHL169510. Right part: WHL169511

Heavy Duty, Drop-In, Swing-Away LegrestsSelect a legrest with extension and type of footplate. Pair (P), left (L), and right (R) configurations are selected by checking the appropriate boxes.70° Drop-In Legrest Upper

Angle Adjustable Footplate(s) with Heel Loops

Accessories



60°-90° Swing-Away Legrest ............................. $81 ea.Pair part: RIG120062. Left: FRMASMB17558. Right: FRMASMB17559Not available with 11"-13" extensions.

60°-90° Swing-Away Legrest, Short ................. $81 ea.Pair part: RIG136481. Left: RIG132607. Right: RIG132609.For use only with 11"-13" lower extensions.

7.25”Wx6”D Extruded Footplate .................. StandardPart pair: FRMASMB7847. Left: FRMASMB7861 Right: FRMASMB7862

8.5”Wx6”D Extruded Footplate .................... StandardPart pair: FRMASMB7848. Left: FRMASMB7863 Right: FRMASMB7864May cause interference on seat widths less than 18.”

4”Wx6”D ............................................................... $85 ea.Pair part: FRMASMB10564. Left: RIG133537. Right: RIG1335605”Wx6”D............................................................... $85 ea.Pair part: FRMASMB10565. Left: RIG133538. Right: RIG1335615”Wx8”D ............................................................... $85 ea.Pair part: FRMASMB10566. Left: RIG133539. Right: RIG133562

6”Wx8”D1 ............................................................. $85 ea.Pair part: FRMASMB10567. Left: RIG133540. Right: RIG1335636”Wx11”D1 ............................................................ $85 ea.Pair part: FRMASMB10568. Left: RIG133541. Right: RIG1335648”Wx11”D2 ............................................................ $85 ea.Pair part: FRMASMB10569. Left: RIG133542. Right: RIG133565

4”Wx6”D ........................................................ $247.50 ea.Pair part: FRMASMB9456. Left: RIG133531. Right: RIG1335525”Wx6”D........................................................ $247.50 ea.Pair part: FRMASMB9457. Left: RIG133532. Right: RIG1335535”Wx8”D ........................................................ $247.50 ea.Pair part: FRMASMB9458. Left: RIG133533. Right: RIG133554

6”Wx8”D1 ...................................................... $247.50 ea.Pair part: FRMASMB9459. Left: RIG133534. Right: RIG1335556”Wx11”D1 ..................................................... $247.50 ea.Pair part: FRMASMB9460. Left: RIG133535. Right: RIG1335588”Wx11”D2 ..................................................... $247.50 ea.Pair part: FRMASMB9461. Left: RIG133536. Right: RIG133559

11”-13” LengthPart: See XRefN/A with Multi-axis. 11”-16.5” LengthPart: See XRefN/A with Angle Adjustable.

13”-16.5” LengthPart: See XRefN/A with Multi-Axis.15.5”-19.5” LengthPart: See XRef

Heel Loops (pair) ..................................................$50Part: FRMASMB7873. HCPCS: E0951Standard on angle adjustable and multi-axis footplates.

Wheel Bumper ............................................$12.50 ea.Part: See XRefGel Neoprene Footrest Sleeve (pair) ..........................$80Part: INDPART2243. HCPCS: K0108

Therafin 31515 Multi-Axis Amputee Support .................$230 ea.Part: INDPART2822. HCPCS: E1020

Therafin 32387 Amputee Support Gel Cover .................$155 ea.Part: INDPART2823. HCPCS: K0108

Swing-Away Legrest Upper

Lower Extension

Extruded Footplate(s)

Angle Adjustable Footplate(s)1The 6”x11” footplates may cause interference with seat widths less than 18”. 2The 8”x11” footplates may cause interference with seat widths less than 20”.

Multi-Axis Footplate(s)1The 6”x11” footplates may cause interference with seat widths less than 18”. 2The 8”x11” footplates may cause interference with seat widths less than 20”.

60°-90° Swing-Away Legrest Accessories

Amputee Supports with Swing-Away UpperEnter a quantity for the amputee supports and covers. A 60°-90° legrest upper must be selected with the amputee support. The support will be configured with the legrest upper side that does not have a lower extension and footplate selected with it.

60°-90° Swing-Away LegrestsAdjustable in 5° increments. Select a legrest upper, a legrest extension, and type of footplate. Pair (P), left (L), and right (R) configurations are selected by checking the appropriate boxes. Select legrest length in following section.

LEGRESTS continued



LEGRESTS continued

Elevating LegrestsSelect a legrest upper, extension, and type of footplate. Pair (P), left (L), and right (R) configurations are selected by checking the appropriate boxes.

7.25”Wx6”D Reinforced Footplate ............... StandardPair part: FRMASMB4748. Left: RIG138055. Right: RIG138056

8.5”Wx6”D Reinforced Footplate ................. StandardPair part: FRMASMB4747. Left: RIG138060. Right: RIG138062May cause interference on seat widths less than 18.”

4”Wx6”D ............................................................... $85 ea.Pair parts: FRMASMB8812 x2.5”Wx6”D............................................................... $85 ea.Pair parts: FRMASMB8811 x2.5”Wx8”D ............................................................... $85 ea.Pair part: FRMASMB4735. Left: RIG137791. Right: RIG137792

6”Wx8”D1 ............................................................. $85 ea.Pair part: FRMASMB4738. Left: RIG137793. Right: RIG1377956”Wx11”D1 ........................................................... $85 ea.Pair part: FRMASMB4741. Left: RIG137796. Right: RIG1377978”Wx11”D2 ........................................................... $85 ea.Pair part: FRMASMB4744. Left: RIG137798. Right: RIG137799

11”-14” LengthPair: FRMASMB4755. Left: RIG138026. Right: RIG138030For reinforced only12”-14.5” LengthPart: See XRefFor angle adjustable only

14”-17” LengthPair: FRMASMB4756. Left: RIG138033. Right: RIG138035For reinforced only14.5”-18” LengthPart: See XRefFor angle adjustable only

Elevating Legrest Assembly ....................................................................................................................................... $162.50 ea.Pair part: FRMASMB6483. Left: RIG138012. Right: RIG138013. HCPCS: K0195Select lower extension and footplates

Elevating Legrest Upper

Lower Extension

Reinforced Cast Footplate(s)

Angle Adjustable Footplate(s) with Heel Loops1The 6”x11” footplates may cause interference with seat widths less than 18”. 2The 8”x11” footplates may cause interference with seat widths less than 20”. 4"x6" and 5"x6" footplates are only available in pairs.

Heavy Duty, Elevating Legrest(s) with Calf Pad(s) ...................................................................................................$162.50 ea.Pair part: FRMASMB6702. Left: FRMASMB8444. Right: FRMASMB8445. HCPCS: K0195

7.25”Wx6”D Extruded Footplate .................. StandardPart pair: FRMASMB4748. Left: RIG138055. Right: RIG138056

8.5”Wx6”D Extruded Footplate .................... StandardPart pair: FRMASMB4747. Left: RIG138060. Right: RIG138062

6”Wx8”D ............................................................... $85 ea.Pair part: FRMASMB4738. Left: RIG137793. Right: RIG137795

6”Wx11”D ............................................................. $85 ea.Pair part: FRMASMB4741. Left: RIG137796. Right: RIG137797.

8”Wx11”D ............................................................. $85 ea.Pair part: FRMASMB4744. Left: RIG137798. Right: RIG137799.May cause interference with seat widths less than 20"

11”-14” LengthPart: FRMASMB4755. Left: RIG138026. Right: RIG138030For reinforced footplates only.

12”-14.5” LengthPart: FRMASMB4752. Left: FRMASMB5391. Right: FRMASMB4723For angle adjustable footplates only.

14”-17” LengthPart: FRMASMB4756. Left: RIG138033. Right: RIG138035For reinforced footplates only.

14.5”-18” LengthPart: FRMASMB4753. Left: FRMASMB4724. Right: FRMASMB5392For angle adjustable footplates only.

Heavy Duty, Elevating LegrestsSelect a legrest upper, extension, and type of footplate. Pair (P), left (L), and right (R) configurations are selected by checking the appropriate boxes.Heavy Duty, Elevating Legrest Selection

Lower Extension

Reinforced Cast Footplate(s)

Angle Adjustable Footplate(s) with Heel Loops1The 6”x11” footplates may cause interference with seat widths less than 18”. 2The 8”x11” footplates may cause interference with seat widths less than 20”. 4"x6" and 5"x6" footplates are only available in pairs.



LEGRESTS continued

SET LEGREST LENGTHREQUIRED with matching left and right legrest configuration. All efforts will be made to accommodate legrest length selection, but minor changes may need to be made to meet shipping guidelines. Some adjustments may be needed upon receipt of the unit. Reference the section’s compatibility matrix for legrest interference. Non-matching or individual legrest configurations lengths are not set by the manufacturer. Part number will be PTOINDV plus the number following the # below. For example, PTOINDV3470.

7” L(#3470)

7.5” L(#3471)

8” L(#3472)

8.5” L(#3473)

9” L(#3474)

9.5” L(#3475)

10” L(#3476)

10.5” L(#3477)

11” L(#3478)

11.5” L(#3479)

12” L(#3480)

12.5” L(#3481)

13” L(#3482)

13.5” L(#3483)

14” L(#3484)

14.5” L(#3485)

15” L(#3486)

15.5” L(#3487)

16” L(#3488)

16.5” L(#3489)

17” L(#3490)

17.5” L(#3491)

18” L(#3492)

18.5” L(#3493)

19” L(#3494)

19.5” L(#3495)

20” L(#3496)

20.5” L(#3497)

21” L(#3498)

21.5” L(#3600)

22” L(#3669)

22.5” L(#3670)

Cushion SelectionSee cushion order form for detailed sizing and pricing.

Match seat selection width and depth Non-matching cushion size, see cushion order form orcushion part number:

CUSHION QUICK PICKOptional. Refer to the specific cushion order form for detailed pricing, sizes, codes, and part numbers. Check the non-matching box and attach a cushion order form for a size other than the previously selected seat width and depth or enter part number below.

Stealth Simplicity® G Cushion (General Use) ....... $110-$165HCPCS: E2601

Stealth Solution® Cushion SPP ..............................$375-$430(Skin Protection & Positioning) HCPCS: E2607-E2608

Synergy Solution® 1 Cushion (Skin Protection) ..... $430-$480HCPCS: E2603-E2604

Stealth Spectrum® Gel Cushion SPP .................... $460-$530(Skin Protection & Positioning) HCPCS: E2607-2608

Stealth Spectrum® Foam Cushion SPP ................ $460-$590(Skin Protection & Positioning) HCPCS: E2607-E2608

Elevating Legrests AccessoriesHeel Loops (pair) ..................................................$50Part: FRMASMB7873. HCPCS: E0951Standard on angle adjustable footplates.Wheel Bumper ............................................$12.50 ea.Part: See XRefAvailable on angle adjustable footplates.

Falcon Gel Padded Knee Adductor Buttons (KBE) (pair) $125Part: INDPART2242. HCPCS: E0953^^Please verify the appropriate billing code to be used for this item with all third-party payors.

ACCESSORIESOptional.

Saddle Bag ......................................$35Part: DWR1020D010

Weather Cover ..............................$168Part: ACCCOVR1022

Flag Holder .....................................$25Limited Recline part: ACCASMB1930Pinchless Hinge part: ACCASMB1907Synergy Seat part: ACCASMB2415

Cup Holder - Style B ......................$20Part: ACCASMB2287Only available on Limited Recline Seats

Cup Holder ......................................$20Part: ACCASMB2634Only available on Pinchless Hinge Seats

Quantum Cup Holder ....................$20Part: ACCASMB2632Only available on Synergy Seat

Tablet Holder ................................$315Part: ACC7120005Only available with Synergy Seat Seats

Cell Phone/Media Holder ............$140Part: ACC7120006Only available with Synergy Seat Seats

Grip Lap Board, 11"x14" ..........$38.95Part: ACC152992

Back Mounted AccessoriesOptional. Only one back mounted accessory can be used at at time. Includes mounting bracket and hardware.

Rear Basket .........................................................................$118Limited Recline part: ACCASMB1914Pinchless Hinge part: FRMASMB1280Synergy Seat part: FRMASMB4821

Cane/Crutch Holder ............................................................$110Limited Recline part: ACCASMB2294Pinchless Hinge part: FRMASMB1270Synergy Seat part: FRMASMB4822HCPCS: E2207

Oxygen Holder ....................................................................$118Limited Recline part: ACCASMB2292Pinchless Hinge part: FRMASMB1269Synergy Seat part: FRMASMB7030HCPCS: E2208

Walker Holder ......................................................................$103Limited Recline part: ACCASMB1912Pinchless Hinge part: FRMASMB1271Synergy Seat part: FRMASMB7031

http://www.pridemobility.com/resourcecenter/downloads/order_forms/order_forms.asp




NOTES

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 application at pridemobility.com/lift-finder

© 2018 Pride Mobility Products Corp. All rights reserved.

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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

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

BATTERIESOptional. The power chair requires two batteries to operate and will be installed if ordered.

NF-22, AGM Battery ........................................................................................................................................................................$330 ea.Part: BATLIQ1018. HCPCS: E2361

http://www.pridemobility.com/lift-finder/

http://www.pridemobility.com/lift-finder/

https://www.youtube.com/user/PrideMobility

https://www.facebook.com/PrideMobilityProductsCorp

https://www.twitter.com/PrideMobility

https://www.instagram.com/pridemobilityproducts/

jazzy 614hd configurable order form · armrests. 14" and 15" back canes are not available...

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