INFINFB3741/RevC/23MAR2018 Page 1 of 3

Jazzy Air® Quick Ship Order Form

Pride® Mobility Products Corporation182 Susquehanna Ave Exeter, PA 18643Phone: 800-800-8586 | Fax: 800-800-1636 | Email: prideorders@pridemobility.com

Account Number: ___________ Date: ________________

Provider Name: __________________________________

Contact: ________________________________________

Phone: ___________________ Fax: _________________

Email: __________________________________________

PO Number: _____________________________________

Marked for: _____________________________________

Ship to Address: _________________________________

City: _____________________ State: ______ Zip: ______

INTRODUCTION

Jazzy Air ........................................................................... $5,799Part: JAIR1001 HCPCS: K0899 - Power Mobility Device, not coded by DME PDAC or does not meet criteria.

BASE MODELREQUIRED. Select a power base. 300 lb. weight capacity. More details and specifications can be found at pridemobility.com/jazzy_power_Chairs.

COLORREQUIRED. Colors shown here may differ from actual product depending on monitor/printer calibration used.

Ruby RedPart: DGN1611019

Pearl WhitePart: DGN160790

Black OnyxPart: DGN160789

Sapphire BluePart: DGN162570

Citrine YellowPart: DGN167717

Rose QuartzPart: DGN167715

Amber OrangePart: DGN167716

GoldPart: DGN167718

SilverPart: DGN167719

Pink TopazPart: DGN1702393

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!

Includes standard options:• Foot platform• Flat-free drive wheels• VR2 joystick• In-line joystick mounting bracket • U-1 batteries• 3.5 Amp off-board charger

FOLD FLAT SEATINGREQUIRED. Select only one seat with size. Seats come with a lap belt.

Captain Seating

16”Wx16”-18”D .................... StandardPart: SET1701577With 60" Lap Belt

18”Wx18”-20”D .................... StandardPart: SET1701578With 60" Lap Belt

20”Wx20”-22”D ................... StandardPart: SET1701579With 60" Lap Belt

16"Wx16"-18"D ..................... Standard

Part: SET1701580With 60" Lap Belt

18”Wx18”-20”D .................... StandardPart: SET1701581With 60" Lap Belt

20”Wx20”-22”D ................... StandardPart: SET1701582With 60" Lap Belt

Solid Seat Pan Seating

INFINFB3741/RevC/23MAR2018 Page 2 of 3

Cushion SelectionOptional. See cushion order form for detailed sizing and pricing.

Account Number: ___________ Date: ________________ Marked for: _____________________________________

ADDITIONAL SHROUDSOptional. Reference colors shown on page 1.

Ruby Red ...................................$127.37Part: DGN1611019

Pearl White ................................$127.37Part: DGN160790

Black Onyx ................................$127.37Part: DGN160789

Sapphire Blue ...........................$127.37Part: DGN162570

Citrine Yellow ............................$127.37Part: DGN167717

Rose Quartz ..............................$127.37Part: DGN167715

Amber Orange ..........................$127.37Part: DGN167716

Gold ...........................................$127.37Part: DGN167718

Silver ..........................................$127.37 Part: DGN167719

Pink Topaz .................................$127.37 Part: DGN1702393

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

Saddle Bag (12.5" x 9.875") .......... $35Part: DWR1020D010

Saddle Bag (11.7.5" x 17") ............. $35Part: DWR1020D016

Cup Holder - Style C ...................... $20Part: ACCASMB2288

Flag Holder ..................................... $25Part: ACCASMB2416

Cell Phone/Media Holder .............. $60Part: ACC1611300

ACCESSORIESOptional.

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

Rear Basket (15.25" x 9.75" x 9.5") ...................................$118 Part: ACC1610772

Cane/Crutch Holder ............................................................$110Part: ACC1610775

Oxygen Holder ....................................................................$118Part: ACC1610773

Walker Holder ......................................................................$103Part: ACC1610776

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: ACCBELT1005

Additional Lap BeltsOptional. The Jazzy Air comes standard with a 60" lap belt. Additional sizes are available below. May increase lead time.

40 Amp AGM (Includes a 5 AMP off-board charger) ..................................................................................................................$175 ea. Part: BATLIQ1002

Battery UpgradeOptional. The Jazzy Air comes standard with two U-1 batteries. Battery upgrade options are available below. May increase lead time.

Joystick Mounting BracketOptional. The Jazzy Air comes standard with an in-line joystick mount. An additional mount may be selected below. May increase lead time.

Retract4 Swing-away Joystick Mounting Bracket .......................................................................................................................... $350 Part: MEC168060

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 ................................ $110-$165(General Use)

Stealth Solution® Cushion SPP ..............................$375-$430(Skin Protection and Positioning)

Synergy Solution® 1 Cushion ............................... $430-$480(Skin Protection)

Stealth Spectrum® Gel Cushion SPP .................... $460-$530(Skin Protection and Positioning)

Stealth Spectrum® Foam Cushion SPP ................ $460-$590(Skin Protection and Positioning)

INFINFB3741/RevC/23MAR2018 Page 3 of 3

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

Pride® Mobility Products Corporation182 Susquehanna Ave Exeter, PA 18643Phone: 800-800-8586 | Fax: 800-800-1636 | Email: prideorders@pridemobility.com

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 applica-tion at pridemobility.com/lift-finder

© 2018 Pride Mobility Products Corp. All rights reserved.

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NOTES_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Account Number: ___________ Date: ________________ Marked for: _____________________________________