Jazzy 614HD Configurable Order Form · armrests. 14" and 15" back canes are not available without...
Transcript of Jazzy 614HD Configurable Order Form · armrests. 14" and 15" back canes are not available without...
Page 1 of 10INFINFB4024/RevA/07SEP2018
Jazzy® 614 HD Configurable Order FormAccount Number: ___________ Date: ________________
Provider Name: __________________________________
Contact: ________________________________________
Phone: ___________________ Fax: _________________
Email: __________________________________________
PO Number: _____________________________________
Marked for: _____________________________________
Ship to Address: _________________________________
City: _____________________ State: ______ Zip: ______
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!
INTRODUCTION
Candy Apple RedPart: SHDASMB5335
Viper BluePart: SHDASMB5336
BASE COLORREQUIRED. Select one shroud color. Colors shown here may differ from actual product depending on monitor/printer calibration used.
Jazzy 614HD 2HD-C ........................................................$5,299Part: J614HD 2HD-C. HCPCS: K0825Captain Seating
Jazzy 614HD 2HD-SS......................................................$5,299Part: J614HD 2HD-SS. HCPCS: K0824Solid Seat Pan Seating
BASE MODELREQUIRED. Select a power base. 450 lb. weight capacity and includes Shark joystick and 4 amp off-board charger. More details and specifica-tions can be found at pridemobility.com/jazzy_power_Chairs.
Pride® Mobility Products Corporation182 Susquehanna Ave Exeter, PA 18643Phone: 800-800-8586 | Fax: 800-800-1636 | Email: [email protected]
JOYSTICK MOUNTING BRACKETSREQUIRED.
Omit Joystick Mounting Bracket
Swing Away JoystickInline Mount (Right)
Swing Away JoystickOffset Mount (Right)
Fixed, In-line, Bracket ......................................................................................................................... StandardPart: FRMASMB11349
Left Side MountPart: PTOINDV1225
Right Side MountPart: PTOINDV1226
Swing-away, Inline, Left Side Mount ............$245Part: ACC142532. HCPCS: E1028
Swing-away, Inline, Right Side Mount .........$245Part: ACC142533. HCPCS: E1028
Swing-away, 1” Offset, Left Side Mount ......$245Part: ACC142751. HCPCS: E1028
Swing-away, 1” Offset, Right Side Mount ...$245Part: ACC142752. HCPCS: E1028
Swing-Away (Retractable) BracketAllows the joystick to retract to the side of the armrest while maintaining the same joystick orientation. "Inline brack-et" will be offset 1" when used with tube style arms. Select "Offset Bracket" to have the joystick inline with armpad on tube style armrests.
Fixed, In-line Joystick Bracket
Base Mounted Foot Platform ................................... StandardPart: FRMASMB13998
Omit base mounted foot platform .........................No ChargePart: PTOINDV3674
BASE MOUNTED FOOT PLATFORMREQUIRED. Select a foot platform option. May interfere with seat mounted legrests. Not available with center mount foot platforms.
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Account Number: ___________ Date: ________________ Marked for: _____________________________________
Deluxe Contour, Limited Recline, High Back with Solid Seat Pan
Solid Seat Pan Seating
JOYSTICK HANDLESOptional. The shark joystick includes a carrot style joystick handle as shown in the power chair image on page 1.
DL Knob .......................................... $35Part: ACCASMB1865. HCPCS: E2323
Wrist Plate ....................................... $45Part: ACCASMB1868. HCPCS: E2323
Round T-Bar .................................... $45Part: ACCASMB1869. HCPCS: E2323
Flat T-Bar ......................................... $45Part: ACCASMB1870. HCPCS: E2323
Straight Bar ..................................... $45Part: ACCASMB1871. HCPCS: E2323
Finger Tube ..................................... $45Part: ACCASMB1872. HCPCS: E2323
PROGRAMMEROptional.
Dynamic Programmer with Flight Adapter .......................................................................................................................................$423Part: ELEASMB4352
CONTOURED SEATINGOptional. Select only one seat with size. Seats come with a lap belt. Maximum weight capacity is 400 lbs. when seat is set at 18”D.
18”Wx18”-20”D ..................... StandardPart: SETASMB6895With 60" Lap Belt
20”Wx18”-20”D ..................... StandardPart: SETASMB6896With 60" Lap Belt
22”Wx20”-22”D .................... StandardPart: SETASMB6897With 70" Lap Belt
Depth-Adjustable, Fold Flat, Limited Recline, High Back
Deluxe Contour, Limited Recline, High Back
Deluxe Contour, High Back
Captain Seating
16”Wx16”D ....................................$450Part: SETASMB2770
16”Wx18”D ....................................$450Part: SETASMB2771
16”Wx20”D....................................$450Part: SETASMB2772
16”Wx22”D....................................$450Part: SETASMB4887
18”Wx16”D ....................................$450Part: SETASMB2775
18”Wx22”D....................................$450Part: SETASMB4888
20”Wx16”D ....................................$450Part: SETASMB2780
20”Wx22”D ................................ $1,000Part: SETASMB4889
20”Wx24”D ...................................$450Part: SETASMB2380
22”Wx18”D ....................................$450Part: SETASMB2171
22”Wx20”D ...................................$450Part: SETASMB2382
22”Wx22”D ...................................$450Part: SETASMB2383
22”Wx24”D ...................................$450Part: SETASMB2384
24”Wx18”D ....................................$450Part: SETASMB2386
24”Wx20”D ...................................$450Part: SETASMB2387
24”Wx22”D ................................ $1,000Part: SETASMB2388
24”Wx24”D ...................................$450Part: SETASMB2389
16”Wx16”D ....................................$450Part: SETASMB317816”Wx18”D ....................................$450Part: SETASMB317916”Wx20”D....................................$450Part: SETASMB318016”Wx22”D....................................$450Part: SETASMB5006
18”Wx16”D ....................................$450Part: SETASMB318118”Wx18”D ....................................$450Part: SETASMB284818”Wx20”D ............................ StandardPart: SETASMB318218”Wx22”D............................ StandardPart: SETASMB5007
20”Wx16”D ....................................$450Part: SETASMB318320”Wx18”D ............................ StandardPart: SETASMB318420”Wx20”D ........................... StandardPart: SETASMB318520”Wx22”D ........................... StandardPart: SETASMB5008
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Account Number: ___________ Date: ________________ Marked for: _____________________________________
CONTOURED SEATING continuedDeluxe Contour, High Back with Solid Seat Pan
20”Wx24”D ........................... StandardPart: SETASMB2982
22”Wx18”D ....................................$450Part: SETASMB2984
22”Wx20”D ................................... $275Part: SETASMB2985
22”Wx22”D ...................................$450Part: SETASMB2986
22”Wx24”D ........................... StandardPart: SETASMB2987
24”Wx18”D ....................................$450Part: SETASMB2989
24”Wx20”D ................................... $275Part: SETASMB2990
24”Wx22”D ...................................$450Part: SETASMB2991
24”Wx24”D ................................... $275Part: SETASMB2992
SYNERGY SEATINGOptional.
Special Measurement Seat
Width:______ Depth:______ Seat Type:_______________
Synergy Seating Frame ........................................................................................................................................................................$434Part: PTOINDV2995
10”-14” Width PackagePart: FRMASMB12043
14”-18” Width PackagePart: FRMASMB12044
16”-20” Width PackagePart: FRMASMB12045
20”-24” Width PackagePart: FRMASMB9867
10” W(#1000)
11” W(#1001)
12” W(#1002)
13” W(#1003)
14” W(#1004)
15” W(#1005)
16” W(#1006)
17” W(#1007)
18” W(#1008)
19” W(#1009)
20” W(#1010)
21” W(#1011)
22” W(#1012)
23” W(#1013)
24” W(#1014)
Synergy Frame Selection
Seat Dimensions - WidthREQUIRED with Synergy seating. Part number is SETWDTH plus number following # below.
Seat Dimensions - DepthREQUIRED with Synergy seating. Part number is SETDPTH plus number following # below.
Seat Dimensions - Depth PackageREQUIRED with Synergy seating.
Seat Dimensions - Width PackageREQUIRED with Synergy seating.
Special Measurement SeatOptional. Special Order selections are not available as a Quick Ship order. Seat size can not exceed 24"W x 24"D. Contact your inside sales specialist for pricing.
Contoured Seat ArmrestsOptional for all seats except depth-adjustable contoured seats.
10”-14” Depth PackagePart: FRMASMB6981
14”-18” Depth PackagePart: FRMASMB6982
15”-20” Depth PackagePart: FRMASMB7732
20”-24” Depth PackagePart: FRMASMB7733
10” D(#1000)
11” D(#1001)
12” D(#1002)
13” D(#1003)
14” D(#1004)
15” D(#1005)
16” D(#1006)
17” D(#1007)
18” D(#1008)
19” D(#1009)
20” D(#1010)
21” D(#1011)
22” D(#1012)
23” D(#1013)
24” D(#1014)
Flip-up, Height Adjustable, Full Length Armrests.................................................................................................................$85 ea.Left part: FRMASMB8614. Right part: FRMASMB8615. HCPCS: E0973
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Account Number: ___________ Date: ________________ Marked for: _____________________________________
Synergy Back ......................................................................$275Part: See XRefSelect a back cane type and height and back height.
TRU-Comfort 4-way Stretch, 20” Width or less ............ $675Part: See XRef. HCPCS: E2620Select back height.
Sling Back ............................................................................. $98Part: See XRefSelect a back height. Available 18"-25" overall heights. Back cane height must match back height. Not available with flip up cantilever arms.
Omit Back .................................................................No ChargePart: PTOINDV1287Select a back cane type and height in following section.
Synergy Back Cane .................................................No ChargePart: FRMASMB15844Select a back cane height.
Flip Forward Back Cane .....................................................$150Part: FRMASMB15846Select a back cane height. Not available with a vent tray, oxygen holder, or cane mounted and cantilever armrests.
2” Mesomorph (1” per side) Back Cane ..........................$195Part: FRMASMB12067Select a cane height.
4” Mesomorph (2” per side) Back Cane ..........................$195Part: FRMASMB12091Select a cane height.
2” Endomorph (1” per side) Back Cane ...........................$195Part: FRMASMB12115Select a cane height.
4” Endomorph (2” per side) Back Cane...........................$195Part: FRMASMB12139Select a cane height.
Push Handles ............................................................. StandardPart: Configuration selection with back cane height
Omit Push Handles .............................................................$125Part: Configuration selection with back cane heightNot available with Sling Back. Minimum cane height is 16".
Accessory Bar .......................................................................................................................................................................................$10012"W-16"W Part: MEC145955. 16"W-20"W Part: MEC143975.
Synergy Back OptionsREQUIRED with Synergy seating. See the Synergy and TRU-Comfort back availability chart for stock order back size ranges. Other size backs may be available with special order and extended lead time.
SYNERGY SEATING continued
Back Selection
Back Cane Selection
Synergy Push Handles
Synergy Accessory Bar
Synergy Overall Back HeightRefer to the Synergy and TRU-Comfort back availability chart for stock order back size ranges. Parts: See XRef, configuration selection with back selection.
13” High
14” High
15” High
16” High
17” High
18” High
19” High
20” High
21” High
22” High
23” High
24” High
25” High
Width
Synergy and TRU-Comfort Back Availability Chart
Synergy Back Synergy or TRU-Comfort Back
Ove
rall
Hei
ght
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Account Number: ___________ Date: ________________ Marked for: _____________________________________
Synergy Back Cane HeightOmit this selection if a TRU-Comfort back is selected. 16" and 17" back canes are not available with a Synergy Back and cane mounted, flip up armrests. 14" and 15" back canes are not available without push handles. Parts: See XRef, configuration selection with push handles selection.
Flip Back, Cane Mounted ArmrestsMay interfere with swing-away laterals
Two-Post, Flip Back, Height Adjustable, Removable ArmrestsNot available with a depth less than 16". Required with flip forward back and laptrays.
Single-Post, Heavy Duty, 8"-12" Height Adjustable, Removable Armrests
Single-Post, Height Adjustable, Removable ArmrestsHeight adjustment from 11"-17" in half-inch increments.
Bariatric, Single-Post, Heavy Duty, Height Adjustable, Removable ArmrestsOnly available with bariatric armpads and in pairs (priced individually).
Single-Post, Heavy Duty, 10"-14" Height Adjustable, Removable Armrests
Height Adjustable, Cantilever ArmrestsHeight adjustment from 11"-17" depends on cane height. Not available with manual recline, flip forward back canes, or cane clamp pushbar.
14” High Canes
15” High Canes
16” High Canes
17” High Canes
18” High Canes
19” High Canes
20” High Canes
21” High Canes
22” High Canes
23” High Canes
24” High Canes
25” High Canes
SYNERGY SEATING continued
Synergy Back OptionsREQUIRED with Synergy seating. Left (L) and right (R) boxes may be checked to configure different size arms within one section arm type.
Synergy ArmpadsREQUIRED with Synergy seating. Waterfall armpads may cause interference with the seat back. Armpads are configured as pairs.
Full Length, Flip Back Armrests ........................ StandardLeft Part: FRMASMB7038. Right part: FRMASMB7039
Desk Length, Flip Back Armrests ...................... StandardLeft part: FRMASMB7040. Right part: FRMASMB7041
Full Length, Two-Post Armrests .......................... $150 ea.Left Part: FRMASMB7062. Right part: FRMASMB7063. HCPCS: E0973
Desk Length, Two-Post Armrests ........................ $150 ea.Left part: FRMASMB7060. Right part: FRMASMB7061. HCPCS: E0973
Full Length, Heavy Duty Armrests, 8"-12" H ........ $85 ea.Left part: FRMASMB9982. Right part: FRMASMB9983. HCPCS: E0973
Desk Length, Heavy Duty Armrests, 8"-12"H ...... $85 ea.Left part: FRMASMB9984. Right part: FRMASMB9985. HCPCS: E0973
Full Length, Heavy Duty Armrests, 10"-14"H ....... $85 ea.Left Part: FRMASMB9986. Right part: FRMASMB9987. HCPCS: E0973
Desk Length, Heavy Duty Armrests, 10"-14"H .... $85 ea.Left part: FRMASMB9988. Right part: FRMASMB9989. HCPCS: E0973
Full Length, Cantilever Armrests ...................... $97.50 ea.Left Part: FRMASMB16188. Right part: FRMASMB16189
Desk Length, Cantilever Armrests ................... $97.50 ea.Left part: FRMASMB16190. Right part: FRMASMB16191
Full Length, Single Post Armrests ......................... $75 ea.Left Part: FRMASMB8594. Right part: FRMASMB8595. HCPCS: E0973
Desk Length, Single Post Armrests ...................... $75 ea.Left part: FRMASMB8592. Right part: FRMASMB8593. HCPCS: E0973
Bariatric Armpads ...................................................No ChargePart: UPSASMB1025.Only available with Bariatric Armrests.
Straight Armpads ...................................................... StandardDesk/Desk part: UPSASMB1022. Full/Full part: UPSASMB1021.Desk/Full part: UPSASMB1023
Waterfall Armpads ...................................................No ChargeDesk/Desk part: UPSASMB1025. Full/Full part: UPSASMB1024. Desk/Full part: UPSASMB1026
No Armpad Selection .............................................No ChargePart: PTOINDV1373
Full Length, Bariatric Armrests, 8"-12" H ................... $85 ea.Left part: FRMASMB6728. Right part: FRMASMB6729. HCPCS: E0973
Full Length, Bariatric Armrests, 10"-14"H .................. $85 ea.Left part: FRMASMB6730. Right part: FRMASMB6731. HCPCS: E0973
Standard Fixed Receiver........................................... StandardPart: FRMASMB16062
Stealth Height Adjustable Receiver .................................$214Tube Arm Part: ST-ARM250C-Q, HCPCS: K0108
JOYSTICK BRACKET RECEIVERREQUIRED.
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Account Number: ___________ Date: ________________ Marked for: _____________________________________
HEADREST PADSOptional. Not available with contoured seating.
Optional Lap BeltsNot available with contoured seating.
Headrest Pads
Headrest Bracket
LAP BELTSREQUIRED except with select contoured seats with included lap belt. Select one lap belt below.
50” Lap BeltPart: ACCBELT1000
60” Lap BeltPart: ACCBELT1002
70” Lap BeltPart: ACCBELT1003
80” Lap BeltPart: ACCBELT1004
90” Lap BeltPart: ACCBELT1001
i-Fit 60” Single Pull, Push Button, Medium ...................... $86(7.5”) Padded, 1.5” Belt (IFPB5213)Part: ST-IFPB5213-Q
i-Fit 60” Single Pull, Push Button, Large .......................... $86Padded (9.5”), 2” Belt (IFPB5314)Part: ST-IFPB5314-Q
i-Fit 60” Single Pull, Push Button, Extra Large ............... $86Padded (11.5”), 2” Belt (IFPB5315)Part: ST-IFPB5315-Q
Stealth’s Worlds Best Removable .............................. $220.50Headrest Bracket (TWB485-1) (C)Part: FRMASMB15999. HCPCS: E1028
Pediatric Offset (HMO475P-17) (E) .............................. $160.50Part: HDWASMB1166. HCPCS: E1028
Stealth Multi-Axis Removable (D) .............................. $160.50Headrest Bracket (HMO475P)Part: HDWASMB1084. HCPCS: E1028
Stealth 8” Comfort Plus (CP450) ............. $151.94Part: POS148484. HCPCS: E0955
Stealth 10” Comfort Plus (CP250) (A) ..... $151.94Part: SETHEAD1057. HCPCS: E0955
Stealth 14” Comfort Plus (CP150) ............ $151.94Part: INDPART2327. HCPCS: E0955
Pediatric Comfort Plus (6”Wx4.5”H) ....... $151.94(CPN350)Part: SETHEAD1069. HCPCS: E0955
Stealth Small Contoured (9.75”Wx3”H) ....$64.20(STL-OTSM250)Part: SETHEAD1052. HCPCS: E0955
Stealth Large Contoured (11”Wx6”H) (B) .$80.25(STL-OTLG150)Part: SETHEAD1053. HCPCS: E0955
Headrests
LEGRESTS
70° HD Drop-in with 12"-14.5" ....................No Charge Length Lower Extension
Pair part: FRMASMB4762. Left: RIG137706. Right: RIG137707
70° HD Drop-in with 14.5-18" ......................No Charge Length Lower Extension
Pair part: FRMASMB4853. Left: RIG137708. Right: RIG137709
6”Wx8”D1 ............................................................. $85 ea.Pair part: FRMASMB4738. Left: RIG137793. Right: RIG137795.
6”Wx11”D1 ............................................................ $85 ea.Pair part: FRMASMB4741. Left: RIG137796. Right: RIG137797.May cause interference on seat widths less than 18".
8”Wx11”D2 ............................................................ $85 ea.Pair part: FRMASMB4744. Left: RIG137708. Right: RIG137709.May cause interference on seat widths less than 20".
Wheel Bumper(s) .............................................................................................................................................................$12.50 ea.Pair part: WHLASMB1578. Left part: WHL169510. Right part: WHL169511
Heavy Duty, Drop-In, Swing-Away LegrestsSelect a legrest with extension and type of footplate. Pair (P), left (L), and right (R) configurations are selected by checking the appropriate boxes.70° Drop-In Legrest Upper
Angle Adjustable Footplate(s) with Heel Loops
Accessories
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Account Number: ___________ Date: ________________ Marked for: _____________________________________
60°-90° Swing-Away Legrest ............................. $81 ea.Pair part: RIG120062. Left: FRMASMB17558. Right: FRMASMB17559Not available with 11"-13" extensions.
60°-90° Swing-Away Legrest, Short ................. $81 ea.Pair part: RIG136481. Left: RIG132607. Right: RIG132609.For use only with 11"-13" lower extensions.
7.25”Wx6”D Extruded Footplate .................. StandardPart pair: FRMASMB7847. Left: FRMASMB7861 Right: FRMASMB7862
8.5”Wx6”D Extruded Footplate .................... StandardPart pair: FRMASMB7848. Left: FRMASMB7863 Right: FRMASMB7864May cause interference on seat widths less than 18.”
4”Wx6”D ............................................................... $85 ea.Pair part: FRMASMB10564. Left: RIG133537. Right: RIG1335605”Wx6”D............................................................... $85 ea.Pair part: FRMASMB10565. Left: RIG133538. Right: RIG1335615”Wx8”D ............................................................... $85 ea.Pair part: FRMASMB10566. Left: RIG133539. Right: RIG133562
6”Wx8”D1 ............................................................. $85 ea.Pair part: FRMASMB10567. Left: RIG133540. Right: RIG1335636”Wx11”D1 ............................................................ $85 ea.Pair part: FRMASMB10568. Left: RIG133541. Right: RIG1335648”Wx11”D2 ............................................................ $85 ea.Pair part: FRMASMB10569. Left: RIG133542. Right: RIG133565
4”Wx6”D ........................................................ $247.50 ea.Pair part: FRMASMB9456. Left: RIG133531. Right: RIG1335525”Wx6”D........................................................ $247.50 ea.Pair part: FRMASMB9457. Left: RIG133532. Right: RIG1335535”Wx8”D ........................................................ $247.50 ea.Pair part: FRMASMB9458. Left: RIG133533. Right: RIG133554
6”Wx8”D1 ...................................................... $247.50 ea.Pair part: FRMASMB9459. Left: RIG133534. Right: RIG1335556”Wx11”D1 ..................................................... $247.50 ea.Pair part: FRMASMB9460. Left: RIG133535. Right: RIG1335588”Wx11”D2 ..................................................... $247.50 ea.Pair part: FRMASMB9461. Left: RIG133536. Right: RIG133559
11”-13” LengthPart: See XRefN/A with Multi-axis. 11”-16.5” LengthPart: See XRefN/A with Angle Adjustable.
13”-16.5” LengthPart: See XRefN/A with Multi-Axis.15.5”-19.5” LengthPart: See XRef
Heel Loops (pair) ..................................................$50Part: FRMASMB7873. HCPCS: E0951Standard on angle adjustable and multi-axis footplates.
Wheel Bumper ............................................$12.50 ea.Part: See XRefGel Neoprene Footrest Sleeve (pair) ..........................$80Part: INDPART2243. HCPCS: K0108
Therafin 31515 Multi-Axis Amputee Support .................$230 ea.Part: INDPART2822. HCPCS: E1020
Therafin 32387 Amputee Support Gel Cover .................$155 ea.Part: INDPART2823. HCPCS: K0108
Swing-Away Legrest Upper
Lower Extension
Extruded Footplate(s)
Angle Adjustable Footplate(s)1The 6”x11” footplates may cause interference with seat widths less than 18”. 2The 8”x11” footplates may cause interference with seat widths less than 20”.
Multi-Axis Footplate(s)1The 6”x11” footplates may cause interference with seat widths less than 18”. 2The 8”x11” footplates may cause interference with seat widths less than 20”.
60°-90° Swing-Away Legrest Accessories
Amputee Supports with Swing-Away UpperEnter a quantity for the amputee supports and covers. A 60°-90° legrest upper must be selected with the amputee support. The support will be configured with the legrest upper side that does not have a lower extension and footplate selected with it.
60°-90° Swing-Away LegrestsAdjustable in 5° increments. Select a legrest upper, a legrest extension, and type of footplate. Pair (P), left (L), and right (R) configurations are selected by checking the appropriate boxes. Select legrest length in following section.
LEGRESTS continued
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Account Number: ___________ Date: ________________ Marked for: _____________________________________
LEGRESTS continued
Elevating LegrestsSelect a legrest upper, extension, and type of footplate. Pair (P), left (L), and right (R) configurations are selected by checking the appropriate boxes.
7.25”Wx6”D Reinforced Footplate ............... StandardPair part: FRMASMB4748. Left: RIG138055. Right: RIG138056
8.5”Wx6”D Reinforced Footplate ................. StandardPair part: FRMASMB4747. Left: RIG138060. Right: RIG138062May cause interference on seat widths less than 18.”
4”Wx6”D ............................................................... $85 ea.Pair parts: FRMASMB8812 x2.5”Wx6”D............................................................... $85 ea.Pair parts: FRMASMB8811 x2.5”Wx8”D ............................................................... $85 ea.Pair part: FRMASMB4735. Left: RIG137791. Right: RIG137792
6”Wx8”D1 ............................................................. $85 ea.Pair part: FRMASMB4738. Left: RIG137793. Right: RIG1377956”Wx11”D1 ........................................................... $85 ea.Pair part: FRMASMB4741. Left: RIG137796. Right: RIG1377978”Wx11”D2 ........................................................... $85 ea.Pair part: FRMASMB4744. Left: RIG137798. Right: RIG137799
11”-14” LengthPair: FRMASMB4755. Left: RIG138026. Right: RIG138030For reinforced only12”-14.5” LengthPart: See XRefFor angle adjustable only
14”-17” LengthPair: FRMASMB4756. Left: RIG138033. Right: RIG138035For reinforced only14.5”-18” LengthPart: See XRefFor angle adjustable only
Elevating Legrest Assembly ....................................................................................................................................... $162.50 ea.Pair part: FRMASMB6483. Left: RIG138012. Right: RIG138013. HCPCS: K0195Select lower extension and footplates
Elevating Legrest Upper
Lower Extension
Reinforced Cast Footplate(s)
Angle Adjustable Footplate(s) with Heel Loops1The 6”x11” footplates may cause interference with seat widths less than 18”. 2The 8”x11” footplates may cause interference with seat widths less than 20”. 4"x6" and 5"x6" footplates are only available in pairs.
Heavy Duty, Elevating Legrest(s) with Calf Pad(s) ...................................................................................................$162.50 ea.Pair part: FRMASMB6702. Left: FRMASMB8444. Right: FRMASMB8445. HCPCS: K0195
7.25”Wx6”D Extruded Footplate .................. StandardPart pair: FRMASMB4748. Left: RIG138055. Right: RIG138056
8.5”Wx6”D Extruded Footplate .................... StandardPart pair: FRMASMB4747. Left: RIG138060. Right: RIG138062
6”Wx8”D ............................................................... $85 ea.Pair part: FRMASMB4738. Left: RIG137793. Right: RIG137795
6”Wx11”D ............................................................. $85 ea.Pair part: FRMASMB4741. Left: RIG137796. Right: RIG137797.
8”Wx11”D ............................................................. $85 ea.Pair part: FRMASMB4744. Left: RIG137798. Right: RIG137799.May cause interference with seat widths less than 20"
11”-14” LengthPart: FRMASMB4755. Left: RIG138026. Right: RIG138030For reinforced footplates only.
12”-14.5” LengthPart: FRMASMB4752. Left: FRMASMB5391. Right: FRMASMB4723For angle adjustable footplates only.
14”-17” LengthPart: FRMASMB4756. Left: RIG138033. Right: RIG138035For reinforced footplates only.
14.5”-18” LengthPart: FRMASMB4753. Left: FRMASMB4724. Right: FRMASMB5392For angle adjustable footplates only.
Heavy Duty, Elevating LegrestsSelect a legrest upper, extension, and type of footplate. Pair (P), left (L), and right (R) configurations are selected by checking the appropriate boxes.Heavy Duty, Elevating Legrest Selection
Lower Extension
Reinforced Cast Footplate(s)
Angle Adjustable Footplate(s) with Heel Loops1The 6”x11” footplates may cause interference with seat widths less than 18”. 2The 8”x11” footplates may cause interference with seat widths less than 20”. 4"x6" and 5"x6" footplates are only available in pairs.
Page 9 of 10INFINFB4024/RevA/07SEP2018
Account Number: ___________ Date: ________________ Marked for: _____________________________________
LEGRESTS continued
SET LEGREST LENGTHREQUIRED with matching left and right legrest configuration. All efforts will be made to accommodate legrest length selection, but minor changes may need to be made to meet shipping guidelines. Some adjustments may be needed upon receipt of the unit. Reference the section’s compatibility matrix for legrest interference. Non-matching or individual legrest configurations lengths are not set by the manufacturer. Part number will be PTOINDV plus the number following the # below. For example, PTOINDV3470.
7” L(#3470)
7.5” L(#3471)
8” L(#3472)
8.5” L(#3473)
9” L(#3474)
9.5” L(#3475)
10” L(#3476)
10.5” L(#3477)
11” L(#3478)
11.5” L(#3479)
12” L(#3480)
12.5” L(#3481)
13” L(#3482)
13.5” L(#3483)
14” L(#3484)
14.5” L(#3485)
15” L(#3486)
15.5” L(#3487)
16” L(#3488)
16.5” L(#3489)
17” L(#3490)
17.5” L(#3491)
18” L(#3492)
18.5” L(#3493)
19” L(#3494)
19.5” L(#3495)
20” L(#3496)
20.5” L(#3497)
21” L(#3498)
21.5” L(#3600)
22” L(#3669)
22.5” L(#3670)
Cushion SelectionSee cushion order form for detailed sizing and pricing.
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 (General Use) ....... $110-$165HCPCS: E2601
Stealth Solution® Cushion SPP ..............................$375-$430(Skin Protection & Positioning) HCPCS: E2607-E2608
Synergy Solution® 1 Cushion (Skin Protection) ..... $430-$480HCPCS: E2603-E2604
Stealth Spectrum® Gel Cushion SPP .................... $460-$530(Skin Protection & Positioning) HCPCS: E2607-2608
Stealth Spectrum® Foam Cushion SPP ................ $460-$590(Skin Protection & Positioning) HCPCS: E2607-E2608
Elevating Legrests AccessoriesHeel Loops (pair) ..................................................$50Part: FRMASMB7873. HCPCS: E0951Standard on angle adjustable footplates.Wheel Bumper ............................................$12.50 ea.Part: See XRefAvailable on angle adjustable footplates.
Falcon Gel Padded Knee Adductor Buttons (KBE) (pair) $125Part: INDPART2242. HCPCS: E0953^^Please verify the appropriate billing code to be used for this item with all third-party payors.
ACCESSORIESOptional.
Saddle Bag ......................................$35Part: DWR1020D010
Weather Cover ..............................$168Part: ACCCOVR1022
Flag Holder .....................................$25Limited Recline part: ACCASMB1930Pinchless Hinge part: ACCASMB1907Synergy Seat part: ACCASMB2415
Cup Holder - Style B ......................$20Part: ACCASMB2287Only available on Limited Recline Seats
Cup Holder ......................................$20Part: ACCASMB2634Only available on Pinchless Hinge Seats
Quantum Cup Holder ....................$20Part: ACCASMB2632Only available on Synergy Seat
Tablet Holder ................................$315Part: ACC7120005Only available with Synergy Seat Seats
Cell Phone/Media Holder ............$140Part: ACC7120006Only available with Synergy Seat Seats
Grip Lap Board, 11"x14" ..........$38.95Part: ACC152992
Back Mounted AccessoriesOptional. Only one back mounted accessory can be used at at time. Includes mounting bracket and hardware.
Rear Basket .........................................................................$118Limited Recline part: ACCASMB1914Pinchless Hinge part: FRMASMB1280Synergy Seat part: FRMASMB4821
Cane/Crutch Holder ............................................................$110Limited Recline part: ACCASMB2294Pinchless Hinge part: FRMASMB1270Synergy Seat part: FRMASMB4822HCPCS: E2207
Oxygen Holder ....................................................................$118Limited Recline part: ACCASMB2292Pinchless Hinge part: FRMASMB1269Synergy Seat part: FRMASMB7030HCPCS: E2208
Walker Holder ......................................................................$103Limited Recline part: ACCASMB1912Pinchless Hinge part: FRMASMB1271Synergy Seat part: FRMASMB7031
Page 10 of 10INFINFB4024/RevA/07SEP2018
NOTES
Pride® Mobility Products Corporation182 Susquehanna Ave Exeter, PA 18643Phone: 800-800-8586 | Fax: 800-800-1636 | Email: [email protected]
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 application at pridemobility.com/lift-finder
© 2018 Pride Mobility Products Corp. All rights reserved.
youtube.com/pridemobility
facebook.com/PrideMobilityProductsCorp
twitter.com/pridemobility
instagram.com/PrideMobilityProducts
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
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
BATTERIESOptional. The power chair requires two batteries to operate and will be installed if ordered.
NF-22, AGM Battery ........................................................................................................................................................................$330 ea.Part: BATLIQ1018. HCPCS: E2361