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Page 1 of 4INFINFB3712/RevH/01MAY2021
16″W × 16″ – 18″D ................ StandardPart: SET131843
18″W × 18″ – 20″D ................ StandardPart: SET131844
20″W × 18″ – 20″D ................ StandardPart: SET131845
Jazzy® Elite ES Quick Ship Order FormAccount Number: ___________ Date: ________________
Provider Name: __________________________________
Contact: ________________________________________
Phone: ___________________ Fax: _________________
Email: __________________________________________
PO Number: _____________________________________
Marked for: _____________________________________
Ship to Address: _________________________________
City: _____________________ State: ______ Zip: ______
Candy Apple RedPart: DGN1702485
Viper BluePart: DGN1702484
BASE COLORREQUIRED. Select one shroud color. Colors shown here may differ from actual product depending on monitor/printer calibration.
Jazzy Elite ES 2S-C ........................................................$5,099Part: JELITEES 2S-C. HCPCS: K0823Captain Seating
Jazzy Elite ES 2S-SS ........................................................$5,099Part: JELITEES 2S-SS. HCPCS: K0822Solid Seat Pan Seating
Standard Features• Front-wheel drive• GC3 joystick• Fixed in-line joystick
mounting bracket • 3.5-amp off-board charger
• Flip-up foot platform• Flat-free, non-marking tires• Depth-adjustable limited
recline high-back seat • 60″ lap belt
BASE MODELREQUIRED. Select a power base. Weight capacity: 300 lbs. Find more details and specifications at pridemobility.com/jazzy-elite-es.
INTRODUCTION
CAPTAIN SEATINGREQUIRED for Jazzy Elite ES 2S-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. (See Page 2 for Jazzy Elite ES 2S-SS Solid Seat Pan Seating.)
Pride® Mobility Products Corporation401 York Avenue, Duryea, PA 18642Phone: 1-800-800-8586 | Fax: 1-800-800-1636 | Email: [email protected]
Depth-Adjustable, Comfort Seat, Limited Recline, High Back
16″W × 16″D .................................$450Part: SETASMB2770
16″W × 18″D .................................$450Part: SETASMB2771
16″W × 20″D ...................................$450Part: SETASMB2772
18″W × 16″D .................................$450Part: SETASMB2775
20″W × 16″D ...................................$450Part: SETASMB2780
Deluxe Contour, Limited Recline, High BackAdditional lead time may apply.
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!
FDA Class II Medical Device*
https://www.pridemobility.com/p/jazzy-elite-eshttps://get.adobe.com/reader/
S
Page 2 of 4INFINFB3712/RevH/01MAY2021
SOLID SEAT PAN SEATINGREQUIRED for Jazzy Elite ES 2S-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 Deluxe Contour Solid Seat Pan Seating.)
16″W × 16″ – 18″D ....................................................... StandardPart: SET145814
18″W × 18″ – 20″D ....................................................... StandardPart: SET145815
Depth-Adjustable, Comfort Seat, Limited Recline, High Back, with Solid Seat Pan
ARMRESTSREQUIRED. The armrests are automatically selected with a Quick Ship order based on seat selection above.
Deluxe Contour, Limited Recline, High Back, with Solid Seat PanAdditional lead time may apply.
16″W × 16″D .......................................................................$450Part: SETASMB3178
16″W × 18″D .......................................................................$450Part: SETASMB3179
18″W × 18″D .......................................................................$450Part: SETASMB2848
16″W × 20″D .......................................................................$450Part: SETASMB3180
18″W × 20″D .......................................................................$450Part: SETASMB3182
20″W × 18″D ............................................................... StandardPart: SETASMB3184
20″W × 20″D ............................................................... StandardPart: SETASMB3185
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 8.5″ × 6″ Foot Plates (pair) .......................................................................................................................... $325Part: KIT124480 HCPCS: K0195
60° – 90° Swing-Away Leg RestsAdjustable in 5° increments.
Elevating Leg Rests
Leg Rest Accessories
LEG RESTSOptional. Some adjustments may be needed upon receipt of the unit.
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.
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
Comfort Seat Armrests (Flip-up, Height-Adjustable, Full-Length)
Deluxe Contour Armrests (Flip-up, Height-Adjustable, Full-Length)
Residual Limb Support, Left ......................................$325 ea.Part: FRMASMB5301. HCPCS: E1020
Residual Limb Support, Right ...................................$325 ea.Part: FRMASMB5300. HCPCS: E1020
Heel Loops (pair), Swing-Away .......................................... $50Part: FRMASMB7873. HCPCS: E0951
Heel Loops (pair), Elevating Leg Rest .............................. $50Part: FRMASMB1503. HCPCS: E0951
https://www.quantumrehab.com/resources/quantum-order-forms.asphttps://www.quantumrehab.com/resources/quantum-order-forms.asphttps://www.quantumrehab.com/resources/quantum-order-forms.asp
Page 3 of 4INFINFB3712/RevH/01MAY2021
ACCESSORIESOptional.
BACK-MOUNTED ACCESSORIESOptional. Only one back-mounted accessory can be used at a time. Includes mounting bracket and hardware.
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
Weather Cover, Medium, Black .........................................$168Part: ACCCOVR1022
Saddle Bag (12.5″ × 9.875″) .................................................. $35Part: DWR1020D010
Cup Holder, Style B for Deluxe Contour Seat .................. $20Part: ACCASMB2287
Cup Holder, Style C for Comfort Seat ............................... $20Part: ACCASMB2288
Flag Holder for Deluxe Contour Seat ................................ $25Part: ACCASMB1930
Flag Holder for Comfort Seat ............................................. $25Part: ACCASMB2629
PP1 Programmer ................................................................ $423Part: ELEASMB4352
Bell-Shaped Foot Platform ............................................... $235Part: RIGASMB7120041
Height-Adjustable Foot Platform Bracket ........................ $50Part: ACCASMB2580
2.1A XLR USB Charger ...................................................$42.99Part: KIT2001524
Unoccupied Transit Kit**
Rear Basket (15.25″ × 9.75″ × 9.5″) for Deluxe Contour Seats ..$118 Part: ACCASMB1914
Rear Basket (15.25″ × 9.75″ × 9.5″) for Comfort Seats ............. $118Part: ACCASMB2537
Cane/Crutch Holder for Deluxe Contour Seats ..............$110Part: ACCASMB2294. HCPCS: E2207
Cane/Crutch Holder for Comfort Seats ...........................$110Part: ACCASMB2540. HCPCS: E2207
Oxygen Tank Holder for Deluxe Contour Seats .............$118Part: ACCASMB2292. HCPCS: E2208
Oxygen Tank Holder for Comfort Seats ..........................$118Part: ACCASMB2651. HCPCS: E2208
Walker Holder for Deluxe Contour Seats ........................$103Part: ACCASMB2541
Walker Holder for Comfort Seats .....................................$103Part: ACCASMB1912
JOYSTICK MOUNTING BRACKETSOptional. The power chair comes standard with an in-line joystick mounting bracket. An additional bracket may be selected below.
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 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
**Custom item — not available as a Quick Ship item. Upgrade to Deluxe Contour Seating is required. Contact your inside sales specialist for pricing.
Page 4 of 4INFINFB3712/RevH/01MAY2021
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
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 Corporation401 York Avenue, Duryea, PA 18642Phone: 1-800-800-8586 | Fax: 1-800-800-1636 | Email: [email protected]
© 2021 Pride Mobility Products Corp. All rights reserved.
youtube.com/pridemobility
facebook.com/PrideMobilityProductsCorp
twitter.com/pridemobility
instagram.com/PrideMobilityProducts
NOTES
*Jazzy® Power Chairs are FDA Class II Medical Devices designed to aid individuals with mobility impairments.
https://www.youtube.com/user/PrideMobilityhttps://www.facebook.com/PrideMobilityProductsCorphttps://www.twitter.com/PrideMobilityhttps://www.instagram.com/pridemobilityproducts/
base model 5: OffButton 43: Page 1: Page 2: Page 3: Page 4:
aButton 46: Page 1: Page 2: Page 3: Page 4:
Print Form 3: Page 1: Page 2: Page 3: Page 4:
SubmitViaEmail 3: Page 1: Page 2: Page 3: Page 4:
seat: OffAccount Number: Date: Provider Name 2: Contact 2: PO Number 2: Marked for: Ship to address 2: Email 2: City 2: State 2: Zip 2: Phone 2: Fax 2: color: Offbase model: Offlegrests: Offcushion quick: OffText Field 85: Text Field 86: FRMASMB16315: OnFRMASMB16316: OnFRMASMB8614: OnFRMASMB8615: OnFRMASMB5301: OffFRMASMB5300: OffHL: OffACCCOVR1022: OffDWR1020D010: OffACCASMB2287: OffACCASMB2288: OffACCASMB1930: OffACCASMB2629: OffELEASMB4352: OffRIGASMB7120041: OffACCASMB2580: Offacc xlr 5: OffACC1704794: Offb acc: Offlapbelts: Offjoystick: Offbranch patch 27: Offbranch patch 26: Offbranch patch 25: Offbranch patch 24: Offbranch patch 23: Offbranch patch 22: OffText Field Notes 6: