Jazzy Elite ES-1 Order Form - Pride Mobility · Deluxe Contour, Limited Recline, High Back...
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Page 1 of 3 INFINFB3770/RevE/03FEB2020 Jazzy ® Elite ES-1 Quick Ship Order Form Account Number: ___________ Date: ________________ Provider Name: __________________________________ Contact: ________________________________________ Phone: ___________________ Fax: _________________ Email:__________________________________________ PO Number:_____________________________________ Marked for: _____________________________________ Ship to Address: _________________________________ City: _____________________ State: ______ Zip: ______ Jazzy Elite ES-1 1S-C ......................................................$5,099 Part: JELITEES-1S-C. HCPCS: K0816 Contoured Seat (Captain) Standard 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-1. INTRODUCTION 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! 16″W × 16″ – 18″D................... Standard With 60″ Lap Belt Part: SET131843 18″W × 18″ – 20″D................... Standard With 60″ Lap Belt Part: SET131844 20″W × 18″ – 20″D................... Standard With 60″ Lap Belt Part: SET131845 CONTOURED SEATING Optional. Select one seat. Seats come with a lap belt. 18″W × 16″D ............................................................................................................................................................................................ $450 With 60″ Lap Belt Part: SETASMB2775 Depth-Adjustable, Comfort Seat, Limited Recline, High Back Deluxe Contour, Limited Recline, High Back Additional lead time may apply. Pride ® Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA 18643 Phone: 1-800-800-8586 | Fax: 1-800-800-1636 | Email: [email protected] 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.
Transcript of Jazzy Elite ES-1 Order Form - Pride Mobility · Deluxe Contour, Limited Recline, High Back...
Page 1 of 3INFINFB3770/RevE/03FEB2020
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: [email protected]
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: [email protected]
© 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.
