Jazzy Select 6 Rental Ready Quick Ship Order Form · 2020-02-21 · Jazzy Select 6-SS ..... $5,099...
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Page 1 of 4 INFINFB3722/RevG/03FEB2020 Jazzy Select 6-C.............................................................. $5,099 Part: JSELECT6-C. HCPCS: K0823 Captain Seating Jazzy Select 6-SS ........................................................... $5,099 Part: JSELECT6-SS. HCPCS: K0822 Solid Seat Pan Seating Jazzy Select 6 ® — Rental Ready Quick Ship Order Form Account 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 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! INTRODUCTION Jazzy Red Part: SHDASMB7110015 Jazzy Blue Part: SHDASMB7110016 BASE COLOR REQUIRED. Select one shroud color. Colors shown here may differ from actual product depending on monitor/printer calibration. BASE MODEL REQUIRED. Select a power base. Weight capacity: 300 lbs. Find more details and specifications at pridemobility.com/jazzy-select-6. Standard Features • Mid-wheel drive technology • Active Trac ® suspension • Height-adjustable foot platform • Flat-free tires • In-line joystick mounting bracket • 3.5-amp off-board charger • 60″ lap belt POWER ELEVATING SEAT Optional. VR2 6-key joystick required. Pride ® Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA 18643 Phone: 1-800-800-8586 | Fax: 1-800-800-1636 | Email: [email protected] Power Elevating Seat ...........................................................................................................................................................................$975 Part: FRMASMB7110112. HCPCS: E2300
Transcript of Jazzy Select 6 Rental Ready Quick Ship Order Form · 2020-02-21 · Jazzy Select 6-SS ..... $5,099...
Page 1 of 4INFINFB3722/RevG/03FEB2020
Jazzy Select 6-C.............................................................. $5,099Part: JSELECT6-C. HCPCS: K0823Captain Seating
Jazzy Select 6-SS ........................................................... $5,099Part: JSELECT6-SS. HCPCS: K0822Solid Seat Pan Seating
Jazzy Select 6® — Rental Ready Quick Ship 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 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!
INTRODUCTION
Jazzy RedPart: SHDASMB7110015
Jazzy BluePart: SHDASMB7110016
BASE COLORREQUIRED. Select one shroud color. Colors shown here may differ from actual product depending on monitor/printer calibration.
BASE MODELREQUIRED. Select a power base. Weight capacity: 300 lbs. Find more details and specifications at pridemobility.com/jazzy-select-6.
Standard Features• Mid-wheel drive technology• Active Trac® suspension• Height-adjustable foot platform• Flat-free tires
• In-line joystick mounting bracket • 3.5-amp off-board charger• 60″ lap belt
POWER ELEVATING SEATOptional. VR2 6-key joystick required.
Pride® Mobility Products Corporation182 Susquehanna Ave., Exeter, PA 18643Phone: 1-800-800-8586 | Fax: 1-800-800-1636 | Email: [email protected]
Power Elevating Seat ...........................................................................................................................................................................$975Part: FRMASMB7110112. HCPCS: E2300
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Account Number: ___________ Date: ________________ Marked for: _____________________________________
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
Elevating Leg Rest with 7.25″ × 6″ Foot Plates (pair) ..... $325Part: KIT124479. HCPCS: K0195
Elevating Leg Rest with 8.5″ × 6″ Foot Plates (pair) ....... $325Part: KIT124480. HCPCS: K0195
LEG RESTSOptional. Some adjustments may be needed upon receipt of the unit.
60° – 90° Swing-Away Leg RestsAdjustable in 5° increments.
Elevating Leg Rests
Leg Rest Accessories
ARMRESTSREQUIRED. The armrests are automatically selected with a Quick Ship order based on seat selection above.
Flip-up, Height-Adjustable, Full-Length Armrests .................................................................................................................$85 ea.Deluxe Contour Seat Left Part: FRMASMB8614. Deluxe Contour Seat Right Part: FRMASMB8615 Comfort Seat Left Part: FRMASMB16315. Comfort Seat Right Part: FRMASMB16316. HCPCS: E0973
*16″W × 16″D .................................. $275Part: SETASMB3178With 60″ Lap Belt
*16″W × 18″D .................................. $275Part: SETASMB3179With 60″ Lap Belt
18″W × 18″D ........................... StandardPart: SETASMB2848With 60″ Lap Belt
18″W × 20″D ........................... StandardPart: SETASMB3182With 60″ Lap Belt
*20″W × 18″D .................................. $275Part: SETASMB3184With 60″ Lap Belt
*20″W × 20″D .................................. $275Part: SETASMB3185With 60″ Lap Belt
Deluxe Contour, Limited Recline, High Back, with Solid Seat PanApplicable when choosing Power Elevating Seat option. Additional lead time may apply.*
Solid Seat Pan Seating
16″W × 16″ – 18″D ..........................................................StandardPart: SET145814With 60″ Lap Belt. Not available with Power Elevating Seating.
18″W × 18″ – 20″D ..........................................................StandardPart: SET145815With 60″ Lap Belt. Not available with Power Elevating Seating.
Depth-Adjustable, Comfort Seat, Limited Recline, High Back, with Solid Seat Pan
18″W × 16″D ............................................................................................................................................................................................$450Part: SETASMB2775With 60″ Lap Belt
Deluxe Contour, Limited Recline, High BackAdditional lead time may apply.
16″W × 16″ – 18″D ................... StandardPart: SET131843With 60″ Lap Belt
18″W × 18″ – 20″D ................... StandardPart: SET131844With 60″ Lap Belt
20″W × 18″ – 20″D ................... StandardPart: SET131845With 60″ Lap Belt
Depth-Adjustable, Comfort Seat, Limited Recline, High Back
SEATINGOptional. Select one seat. Seats come with a 60″ lap belt.
Captain Seating
Residual Limb Support ......................................... $325 ea.Left part: FRMASMB5301. Right part: FRMASMB5300 HCPCS: E1020
Heel Loops (pair) .................................................................. $50ELR part: FRMASMB1503. S/A part: FRMASMB7873 HCPCS: E0951
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Rear Basket (15.25″ × 9.75″ × 9.5″) ......................................$118 Deluxe Contour part: ACCASMB1914. Comfort part: ACCASMB2537
Cane/Crutch Holder ............................................................$110Deluxe Contour part: ACCASMB2294. Comfort part: ACCASMB2540HCPCS: E2207
Oxygen Tank Holder ...........................................................$118Deluxe Contour part: ACCASMB2292. Comfort part: ACCASMB2651 HCPCS: E2208
Walker Holder ......................................................................$103Deluxe Contour part: ACCASMB2541. Comfort part: ACCASMB1912
Account Number: ___________ Date: ________________ Marked for: _____________________________________
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)
Back-Mounted AccessoriesOptional. Only one back-mounted accessory can be used at a time. Includes mounting bracket and hardware.
Additional Lap BeltsOptional. Seats come with a 60″ lap belt. An additional lap belt may be selected below.
70″ Lap Belt ................................ $39.90 Part: ACCBELT1003
80″ Lap Belt ............................... $39.90 Part: ACCBELT1004
90″ Lap Belt ............................... $39.90 Part: ACCBELT1005
ACCESSORIESOptional.
Weather Cover, Medium, Black .........................................$168Part: ACCCOVR1022
Saddle Bag (12.5″ × 9.875″) .................................................. $35Part: DWR1020D010
Bell-Shaped Foot Platform ............................................... $235Part: RIGASMB7120041
PP1 Programmer ................................................................ $423Part: CTLDC1388
Flag Holder ........................................................................... $25Deluxe Contour part: ACCASMB1930. Comfort part: ACCASMB2629
Cup Holder ............................................................................ $20Style B, Deluxe Contour part: ACCASMB2287 Style C, Comfort part: ACCASMB2288
XLR USB Charger ................................................................ $38Part: ACC1704791
Unoccupied Transit Kit ......................................................$100Part: KIT1805521Used on Comfort Seats only — see SEATING on Page 2.
Swing-Away, In-line ..................................................... $245Left part: ACC148364. Right part: ACC148365HCPCS: E1028
Swing-Away, 1″ Offset ................................................. $245Left part: ACC148366. Right part: ACC148367HCPCS: E1028
JOYSTICKREQUIRED. The joystick may be automatically selected based on the power base selection.
GC3 .............................................................................. StandardPart: ELEASMB7226Used with non-power elevating seats
VR2, 6-key ........................................................................... $200Part: CTLDC1498Required with power elevating seats
BATTERIESREQUIRED. The Power Chair requires two batteries. The batteries are automatically selected with a Quick Ship order.
U-1 .................................................................................................................................................................................................... $133 ea.Part: BATLIQ1017. HCPCS: E2365
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.
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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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Special Measurement Seat
SPECIAL MEASUREMENT SEATOptional. Special measurement seats are not available as a Quick Ship order. Seat size cannot exceed 20″W × 20″D. Contact your inside sales specialist for pricing.
Width:______ Depth:______ Seat Type:_______________
Account Number: ___________ Date: ________________ Marked for: _____________________________________
NOTES
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
