jazzy elite hd order form - pride mobility products corp....swing-away leg rest with 7.25″× 6″...

of 4INFINFB3771/RevE/01MAY2021

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

Provider Name: __________________________________

Contact: ________________________________________

Phone: ___________________ Fax: _________________

Email: __________________________________________

PO Number: _____________________________________

Marked for: _____________________________________

Ship to Address: _________________________________

City: _____________________ State: ______ Zip: ______

Jazzy RedPart: SHDASMB7120084

Jazzy BluePart: SHDASMB7120085

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

Jazzy Elite HD 2HD-C ..................................................... $5,299Part: JELITEHD 2HD-C. HCPCS: K0825Captain Seating

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

Standard Features• Front-wheel drive• Angle-adjustable foot platform• Dynamic joystick

• In-line joystick mounting bracket• 5-amp off-board charger• Flat-free tires

BASE MODELREQUIRED. Select a power base. Weight capacity: 450 lbs. Find more details and specifications at pridemobility.com/jazzy-elite-hd.

INTRODUCTIONThis form is interactive when viewed in Adobe Acrobat Reader and may not function correctly if opened with other applications. HCPCS codes provided should not be considered as legal advice and do not guarantee reimbursement. DME providers are responsi-ble 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!

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

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

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

NF-22, 55Ah ....................................................................................................................................................................................$330 ea.Part: BATLIQ1018. HCPCS: E2361

ELITE HD

FDA Class II Medical Device*

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


Elevating Leg Rests with 8.5″ × 6″ Foot Plates (pair) .....$325Part: FRMASMB3806. HCPCS: K0195

Elevating Leg Rests

Leg Rest Accessories

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

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

LEG RESTSOptional.

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

Deluxe Contour, High Back, with Solid Seat Pan

SOLID SEAT PAN SEATINGREQUIRED with Jazzy Elite HD 2HD-SS. Select one seat. Seats come with a 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 24″W × 24″D. (NOTE: Seat backs are approximately 2″ wider than seat bases on Deluxe Contour Solid Seat Pan Seating.)

Depth-Adjustable, Limited Recline, High Back with Quick-Release Seat Frame and Comfort ArmrestsMaximum weight capacity is 400 lbs. when seat is set at 18″D.

Deluxe Contour, High Back

Deluxe Contour, Limited Recline, High Back

18″W × 18″ – 20″D....................StandardPart: SET131844 With 60″ Lap Belt

20″W × 18″ – 20″D ....................StandardPart: SET131845 With 60″ Lap Belt

22″W × 20″ – 22″D ...................StandardPart: SET1808330 With 70″ Lap Belt

20″W × 22″D ................................... $450Part: SETASMB4889 With 60″ Lap Belt

CAPTAIN SEATINGREQUIRED with Jazzy Elite HD 2HD-C. Select one seat. Seats come with a 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 24″W × 24″D.

22″W × 18″D ...................................$450Part: SETASMB2171With 70″ Lap Belt





18″W × 18″D ..................................................................StandardPart: SETASMB2848With 60″ Lap Belt





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


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

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

50″ Lap Belt ............ $39.90Part: ACCBELT1000

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

80″ Lap Belt ............ $39.90 Part: ACCBELT1004

90″ Lap Belt ............ $39.90 Part: ACCBELT1001

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

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

Cup Holder, Style B ..............................................................$20Part: ACCASMB2287

Flag Holder ............................................................................$25Part: ACCASMB1930

Dynamic 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**

ACCESSORIESOptional.

Rear Basket (15.25″ × 9.75″ × 9.5″) ...................................... $118 Part: ACCASMB1914

Cane/Crutch Holder ............................................................ $110Part: ACCASMB2294. HCPCS: E2207

Oxygen Tank Holder ........................................................... $118Part: ACCASMB2292. HCPCS: E2208

Walker Holder ......................................................................$103Part: ACCASMB2541

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

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.

Swing-Away Joystick Mount, In-line, Left .......................$245Part: KIT2002912. HCPCS: E1028

Swing-Away Joystick Mount, In-line, Right ....................$245Part: KIT2003310. HCPCS: E1028

Swing-Away Joystick Mount, 1″ Offset, Left ...................$245Part: ACC148370. HCPCS: E1028

Swing-Away Joystick Mount, 1″ Offset, Right ................$245Part: ACC148371. HCPCS: E1028

Swing-Away JoystickIn-line Mount (Right)

Swing-Away JoystickOffset Mount (Right)

ARMRESTSREQUIRED. The armrests are automatically selected with Quick Ship orders.

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

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

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

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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

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Account 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: Offseat: Offrl l: Offrl r: Offhl: Offlapbelts7: Offlapbelts: Offlapbelts22: Offaccessories: Offaccessories c 3: Offaccessories b: Offaccessories a: Offaccessories dp: Offaccessories bsfp: Offfoot 10: Offacc xlr: Offfoot 11: Offrear access: Offcushion quick: OffText Field 81: Text Field 86: js: OffFRMASMB8615: Deluxe Contour Armrest, LeftFRMASMB8616: Onbranch patch 26: Offbranch patch 25: Offbranch patch 24: Offbranch patch 23: Offbranch patch 22: Offbranch patch 21: OffNotes 2:

jazzy elite hd order form - pride mobility products corp....swing-away leg rest with 7.25″× 6″...

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