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Jazzy® Elite ES-1 Quick Ship Order FormAccount Number: ___________ Date: ________________

Provider Name: __________________________________

Contact: ________________________________________

Phone: ___________________ Fax: _________________

Email: __________________________________________

PO Number: _____________________________________

Marked for: _____________________________________

Ship to Address: _________________________________

City: _____________________ State: ______ Zip: ______

Jazzy Elite ES-1 1S-C ......................................................$5,099Part: JELITEES-1S-C. HCPCS: K0816Contoured Seat (Captain) Standard

Standard Features• Front-wheel drive• GC3 joystick

• In-line joystick mounting bracket • 3-amp off-board charger

BASE MODELREQUIRED. Select a power base. Weight capacity: 300 lbs. Find more details and specifications at pridemobility.com/jazzy-elite-es-1.

INTRODUCTIONThis 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!

16″W × 16″ – 18″D ................... StandardWith 60″ Lap BeltPart: SET131843

18″W × 18″ – 20″D ................... StandardWith 60″ Lap BeltPart: SET131844

20″W × 18″ – 20″D ................... StandardWith 60″ Lap BeltPart: SET131845

CONTOURED SEATINGOptional. Select one seat. Seats come with a lap belt.

18″W × 16″D ............................................................................................................................................................................................$450With 60″ Lap BeltPart: SETASMB2775

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

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

Pride® Mobility Products Corporation182 Susquehanna Ave., Exeter, PA 18643Phone: 1-800-800-8586 | Fax: 1-800-800-1636 | Email: prideorders@pridemobility.com

Candy Apple RedPart: DGN1702485

Viper BluePart: DGN1702484

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

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Account Number: ___________ Date: ________________ Marked for: _____________________________________

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

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

Cup Holder .............................................................................$20Style C, Comfort part: ACCASMB2288 Style B, Deluxe Contour part: ACCASMB2287

Flag Holder ............................................................................$25Comfort part: ACCASMB2629 Deluxe Contour part: ACCASMB1930

PP1 Programmer .................................................................$423Part: CTLDC1388

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

USB XLR Charger .................................................................$38Part: ACC1704791

Unoccupied Transit Kit ......................................................$100Part: KIT1805521Used on Comfort Seats only — see SEATING on Page 1.

ACCESSORIESOptional.

Rear Basket (15.25″ × 9.75″ × 9.5″) ...................................... $118 Deluxe Contour part: ACCASMB1914. Comfort part: ACCASMB2537

Cane/Crutch Holder ............................................................ $110Comfort part: ACCASMB2540. Deluxe Contour part: ACCASMB2294HCPCS: E2207

Oxygen Tank Holder ........................................................... $118Comfort part: ACCASMB2651. Deluxe Contour part: ACCASMB2292HCPCS: E2208

Walker Holder ......................................................................$103Comfort part: ACCASMB1912. Deluxe Contour part: ACCASMB2541

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

Elevating Leg Rests with 7.25″ × 6″ Foot Plates (pair)......$325Part: KIT124479 HCPCS: K0195

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

Elevating Leg Rests

Residual Limb Support ..........................................$325 ea.Left part: FRMASMB5301. Right part: FRMASMB5300HCPCS: E1020

Heel Loops (pair) ...................................................................$50ELR part: FRMASMB1503. S/A part: FRMASMB7873 HCPCS: E0951

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.

Flip-up, Height-Adjustable, Full-Length Armrests .................................................................................................................$85 ea.Comfort Seat Left part: FRMASMB16315. Right: FRMASMB16316 Deluxe Contour Left part: FRMASMB8614. Right: FRMASMB8615HCPCS: E0973

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

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

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Account Number: ___________ Date: ________________ Marked for: _____________________________________

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 Corporation182 Susquehanna Ave., Exeter, PA 18643Phone: 1-800-800-8586 | Fax: 1-800-800-1636 | Email: prideorders@pridemobility.com

© 2020 Pride Mobility Products Corp. All rights reserved.

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REFERENCE ORDER FORMSOptional. Select below to note that additional order forms will accompany this order form.

Synergy Seat (May increase lead time)

NOTES

Swing-Away, In-line ......................................................$245Left part: ACC148364. Right part: ACC148365HCPCS: E1028

Swing-Away, 1″ Offset ..................................................$245Left part: ACC148366. Right part: ACC148367HCPCS: E1028

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

Swing-Away JoystickIn-line Mount (Right)

Swing-Away JoystickOffset Mount (Right)

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

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