Page 1 of 4 INFINFB3769/RevG/07OCT2020 Jazzy ® Elite ES Portable Quick Ship Order Form Account Number: ___________ Date: ________________ Provider Name: __________________________________ Contact: ________________________________________ Phone: ___________________ Fax: _________________ Email:__________________________________________ PO Number:_____________________________________ Marked for: _____________________________________ Ship to Address: _________________________________ City: _____________________ State: ______ Zip: ______ Candy Apple Red Part: DGN1702485 Viper Blue Part: DGN1702484 BASE COLOR REQUIRED. Select one color. Colors shown here may differ from actual product depending on monitor/printer calibration. Jazzy Elite ES Portable 2S-P-C .................................... $5,099 Part: JELITEES-P 2S-P-C. HCPCS: K0821 Captain Seating Jazzy Elite ES Portable 2S-P-SS .................................. $5,099 Part: JELITEES-P 2S-P-SS. HCPCS: K0820 Solid Seat Pan Seating Standard Features • Front-wheel drive • GC3 joystick • In-line joystick mounting bracket • 3-amp off-board charger BASE MODEL REQUIRED. Select a power base. Weight capacity: 300 lbs. Find more details and specifications at pridemobility.com/jazzy-elite-es-portable. INTRODUCTION Depth-Adjustable, Comfort Seat, Limited Recline, High Back Deluxe Contour, Limited Recline, High Back Additional lead time may apply. Pride ® Mobility Products Corporation 401 York Avenue, Duryea, PA 18642 Phone: 1-800-800-8586 | Fax: 1-800-800-1636 | Email: [email protected]16″W × 16″ – 18″D................... Standard Part: SET131843 18″W × 18″ – 20″D................... Standard Part: SET131844 20″W×18″–20″D................... Standard Part: SET131845 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! CAPTAIN SEATING REQUIRED for JELITEES-P 2S-P-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. 16″W × 16″D ................................... $450 Part: SETASMB2770 16″W × 18″D ................................... $450 Part: SETASMB2771 18″W × 16″D ................................... $450 Part: SETASMB2775 FDA Class II Medical Device*
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Jazzy Elite ES Portable Order Form - Pride Mobility …...Elevating Leg Rests Leg Rest Accessories Swing-Away Leg Rest with 7.25″× ..6″ Foot Plates (pair).. $162 Part: RIG133656
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Page 1 of 4INFINFB3769/RevG/07OCT2020
Jazzy® Elite ES Portable Quick Ship Order FormAccount Number: ___________ Date: ________________
Provider Name: __________________________________
Contact: ________________________________________
Phone: ___________________ Fax: _________________
Email: __________________________________________
PO Number: _____________________________________
Marked for: _____________________________________
Ship to Address: _________________________________
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!
CAPTAIN SEATINGREQUIRED for JELITEES-P 2S-P-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.
Deluxe Contour, Limited Recline, High Back, with Solid Seat PanAdditional lead time may apply.
Page 2 of 4INFINFB3769/RevG/07OCT2020
Elevating Leg Rests with 8.5″ × 6″ Foot Plates (pair) ....................................................................................................................... $325Part: KIT124480 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.
ARMRESTSREQUIRED. The armrests are automatically selected with a Quick Ship order based on seat selection above.
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.
Depth-Adjustable, Comfort Seat, Limited Recline, High Back, with Solid Seat Pan16″W × 16″ – 18″D ..........................................................StandardPart: SET145814
SOLID SEAT PAN SEATINGREQUIRED for JELITEES-P 2S-P-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 Solid Seat Pan Seating.)
Residual Limb Support, Left .......................................$325 ea.Part: FRMASMB5301. HCPCS: E1020
Residual Limb Support, Right ....................................$325 ea.Part: FRMASMB5300. HCPCS: E1020
Heel Loops (pair) for Swing-Away Leg Rests ...................$50Part: FRMASMB7873. HCPCS: E0951
Heel Loops (pair) for Elevating Leg Rests ........................$50Part: FRMASMB1503. HCPCS: E0951
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
JOYSTICK MOUNTING BRACKETSOptional. The power chair comes standard with an in-line joystick mounting bracket. An additional bracket 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
BACK-MOUNTED ACCESSORIESOptional. Only one back-mounted accessory can be used at a time. Includes mounting bracket and hardware.