jazzy elite es order form - pride mobility products corp....s ffb31/re/oct page 2 of 4 solid seat...

of 4INFINFB3712/RevH/01MAY2021

16″W × 16″ – 18″D ................ StandardPart: SET131843



Jazzy® Elite ES Quick Ship Order FormAccount Number: ___________ Date: ________________

Provider Name: __________________________________

Contact: ________________________________________

Phone: ___________________ Fax: _________________

Email: __________________________________________

PO Number: _____________________________________

Marked for: _____________________________________

Ship to Address: _________________________________

City: _____________________ State: ______ Zip: ______

Candy Apple RedPart: DGN1702485

Viper BluePart: DGN1702484

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

Jazzy Elite ES 2S-C ........................................................$5,099Part: JELITEES 2S-C. HCPCS: K0823Captain Seating

Jazzy Elite ES 2S-SS ........................................................$5,099Part: JELITEES 2S-SS. HCPCS: K0822Solid Seat Pan Seating

Standard Features• Front-wheel drive• GC3 joystick• Fixed in-line joystick

mounting bracket • 3.5-amp off-board charger

• Flip-up foot platform• Flat-free, non-marking tires• Depth-adjustable limited

recline high-back seat • 60″ lap belt

BASE MODELREQUIRED. Select a power base. Weight capacity: 300 lbs. Find more details and specifications at pridemobility.com/jazzy-elite-es.

INTRODUCTION

CAPTAIN SEATINGREQUIRED for Jazzy Elite ES 2S-C. Select one seat. All seats shown include a 60″ lap belt. Deluxe Contour seats are not available as a Quick Ship order, and additional lead time may apply. Seat sizes on this unit cannot exceed 20″W × 20″D. (See Page 2 for Jazzy Elite ES 2S-SS Solid Seat Pan Seating.)

Pride® Mobility Products Corporation401 York Avenue, Duryea, PA 18642Phone: 1-800-800-8586 | Fax: 1-800-800-1636 | Email: [email protected]

Depth-Adjustable, Comfort Seat, Limited Recline, High Back

16″W × 16″D .................................$450Part: SETASMB2770

16″W × 18″D .................................$450Part: SETASMB2771

16″W × 20″D ...................................$450Part: SETASMB2772

18″W × 16″D .................................$450Part: SETASMB2775

20″W × 16″D ...................................$450Part: SETASMB2780

Deluxe Contour, Limited Recline, High BackAdditional lead time may apply.

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 power chair. Pride Providers may contact Technical Services for accurate parts ordering.

Thank you for choosing Pride Mobility Products!

FDA Class II Medical Device*

https://www.pridemobility.com/p/jazzy-elite-eshttps://get.adobe.com/reader/

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Page 2 of 4INFINFB3712/RevH/01MAY2021

SOLID SEAT PAN SEATINGREQUIRED for Jazzy Elite ES 2S-SS. Select one seat. All seats shown include a 60″ lap belt. Deluxe Contour seats are not available as a Quick Ship order, and additional lead time may apply. Seat sizes on this unit cannot exceed 20″W × 20″D. (NOTE: Seat backs are approximately 2″ wider than seat bases on Deluxe Contour Solid Seat Pan Seating.)

16″W × 16″ – 18″D ....................................................... StandardPart: SET145814

18″W × 18″ – 20″D ....................................................... StandardPart: SET145815

Depth-Adjustable, Comfort Seat, Limited Recline, High Back, with Solid Seat Pan

ARMRESTSREQUIRED. The armrests are automatically selected with a Quick Ship order based on seat selection above.

Deluxe Contour, Limited Recline, High Back, with Solid Seat PanAdditional lead time may apply.

16″W × 16″D .......................................................................$450Part: SETASMB3178

16″W × 18″D .......................................................................$450Part: SETASMB3179

18″W × 18″D .......................................................................$450Part: SETASMB2848

16″W × 20″D .......................................................................$450Part: SETASMB3180

18″W × 20″D .......................................................................$450Part: SETASMB3182

20″W × 18″D ............................................................... StandardPart: SETASMB3184

20″W × 20″D ............................................................... StandardPart: SETASMB3185

Swing-Away Leg Rest with 7.25″ × 6″ Foot Plates (pair) ..$162Part: RIG133656

Swing-Away Leg Rest with 8.5″ × 6″ Foot Plates (pair) ....$162Part: RIG133659

Elevating Leg Rest with 8.5″ × 6″ Foot Plates (pair) .......................................................................................................................... $325Part: KIT124480 HCPCS: K0195

60° – 90° Swing-Away Leg RestsAdjustable in 5° increments.

Elevating Leg Rests

Leg Rest Accessories

LEG RESTSOptional. Some adjustments may be needed upon receipt of the unit.

Match seat width and depth — see cushion order form or cushion part number:

Non-matching cushion size — see cushion order form or cushion part number:

CUSHION QUICK PICKOptional. Refer to the specific cushion order form for pricing, sizes, codes, and part numbers. If the cushion size matches the selected seat size, check Match seat width and depth. If the cushion size differs from the seat size, check Non-matching cushion size. Attach the cushion order form, or fill in the cushion part number below.

Comfort Seat Armrest, Left ..........................................$85 ea.Part: FRMASMB16315. HCPCS: E0973

Comfort Seat Armrest, Right .......................................$85 ea.Part: FRMASMB16316. HCPCS: E0973

Deluxe Contour Armrest, Left ......................................$85 ea.Part: FRMASMB8614. HCPCS: E0973

Deluxe Contour Armrest, Right ...................................$85 ea.Part: FRMASMB8615. HCPCS: E0973

Comfort Seat Armrests (Flip-up, Height-Adjustable, Full-Length)

Deluxe Contour Armrests (Flip-up, Height-Adjustable, Full-Length)

Residual Limb Support, Left ......................................$325 ea.Part: FRMASMB5301. HCPCS: E1020

Residual Limb Support, Right ...................................$325 ea.Part: FRMASMB5300. HCPCS: E1020

Heel Loops (pair), Swing-Away .......................................... $50Part: FRMASMB7873. HCPCS: E0951

Heel Loops (pair), Elevating Leg Rest .............................. $50Part: FRMASMB1503. HCPCS: E0951

https://www.quantumrehab.com/resources/quantum-order-forms.asphttps://www.quantumrehab.com/resources/quantum-order-forms.asphttps://www.quantumrehab.com/resources/quantum-order-forms.asp


ACCESSORIESOptional.

BACK-MOUNTED ACCESSORIESOptional. Only one back-mounted accessory can be used at a time. Includes mounting bracket and hardware.

BATTERIESREQUIRED. The Power Chair requires two batteries. The batteries are automatically selected with a Quick Ship order.

U-1, 27Ah .........................................................................................................................................................................................$133 ea.Part: BATLIQ1026. HCPCS: E2365

Weather Cover, Medium, Black .........................................$168Part: ACCCOVR1022

Saddle Bag (12.5″ × 9.875″) .................................................. $35Part: DWR1020D010

Cup Holder, Style B for Deluxe Contour Seat .................. $20Part: ACCASMB2287

Cup Holder, Style C for Comfort Seat ............................... $20Part: ACCASMB2288

Flag Holder for Deluxe Contour Seat ................................ $25Part: ACCASMB1930

Flag Holder for Comfort Seat ............................................. $25Part: ACCASMB2629

PP1 Programmer ................................................................ $423Part: ELEASMB4352

Bell-Shaped Foot Platform ............................................... $235Part: RIGASMB7120041

Height-Adjustable Foot Platform Bracket ........................ $50Part: ACCASMB2580

2.1A XLR USB Charger ...................................................$42.99Part: KIT2001524

Unoccupied Transit Kit**

Rear Basket (15.25″ × 9.75″ × 9.5″) for Deluxe Contour Seats ..$118 Part: ACCASMB1914

Rear Basket (15.25″ × 9.75″ × 9.5″) for Comfort Seats ............. $118Part: ACCASMB2537

Cane/Crutch Holder for Deluxe Contour Seats ..............$110Part: ACCASMB2294. HCPCS: E2207

Cane/Crutch Holder for Comfort Seats ...........................$110Part: ACCASMB2540. HCPCS: E2207

Oxygen Tank Holder for Deluxe Contour Seats .............$118Part: ACCASMB2292. HCPCS: E2208

Oxygen Tank Holder for Comfort Seats ..........................$118Part: ACCASMB2651. HCPCS: E2208

Walker Holder for Deluxe Contour Seats ........................$103Part: ACCASMB2541

Walker Holder for Comfort Seats .....................................$103Part: ACCASMB1912

JOYSTICK MOUNTING BRACKETSOptional. The power chair comes standard with an in-line joystick mounting bracket. An additional bracket may be selected below.

70″ Lap Belt .............................$39.90 Part: ACCBELT1003



LAP BELTSOptional. Seats come with a 60″ lap belt. An additional lap belt may be selected below.

Swing-Away Joystick Mount, In-line, Left ...................... $245Part: KIT1906945. HCPCS: E1028

Swing-Away Joystick Mount, In-line, Right ................... $245Part: KIT1905628. HCPCS: E1028

Swing-Away Joystick Mount, 1″ Offset, Left ................. $245Part: ACC148366. HCPCS: E1028

Swing-Away Joystick Mount, 1″ Offset, Right ............... $245Part: ACC148367. HCPCS: E1028

**Custom item — not available as a Quick Ship item. Upgrade to Deluxe Contour Seating is required. Contact your inside sales specialist for pricing.


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

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

Pride® Mobility Products Corporation401 York Avenue, Duryea, PA 18642Phone: 1-800-800-8586 | Fax: 1-800-800-1636 | Email: [email protected]

© 2021 Pride Mobility Products Corp. All rights reserved.

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NOTES

*Jazzy® Power Chairs are FDA Class II Medical Devices designed to aid individuals with mobility impairments.

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Print Form 3: Page 1: Page 2: Page 3: Page 4:

SubmitViaEmail 3: Page 1: Page 2: Page 3: Page 4:

seat: OffAccount Number: Date: Provider Name 2: Contact 2: PO Number 2: Marked for: Ship to address 2: Email 2: City 2: State 2: Zip 2: Phone 2: Fax 2: color: Offbase model: Offlegrests: Offcushion quick: OffText Field 85: Text Field 86: FRMASMB16315: OnFRMASMB16316: OnFRMASMB8614: OnFRMASMB8615: OnFRMASMB5301: OffFRMASMB5300: OffHL: OffACCCOVR1022: OffDWR1020D010: OffACCASMB2287: OffACCASMB2288: OffACCASMB1930: OffACCASMB2629: OffELEASMB4352: OffRIGASMB7120041: OffACCASMB2580: Offacc xlr 5: OffACC1704794: Offb acc: Offlapbelts: Offjoystick: Offbranch patch 27: Offbranch patch 26: Offbranch patch 25: Offbranch patch 24: Offbranch patch 23: Offbranch patch 22: OffText Field Notes 6:

jazzy elite es order form - pride mobility products corp....s ffb31/re/oct page 2 of 4 solid seat...

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