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Jazzy® Elite ES Portable 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 color. Colors shown here may differ from actual product depending on monitor/printer calibration.

Jazzy Elite ES Portable 2S-P-C .................................... $5,099Part: JELITEES-P 2S-P-C. HCPCS: K0821Captain Seating

Jazzy Elite ES Portable 2S-P-SS .................................. $5,099Part: JELITEES-P 2S-P-SS. HCPCS: K0820Solid Seat Pan Seating

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-portable.

INTRODUCTION

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

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

Pride® Mobility Products Corporation401 York Avenue, Duryea, PA 18642Phone: 1-800-800-8586 | Fax: 1-800-800-1636 | Email: prideorders@pridemobility.com

16″W × 16″ – 18″D ................... StandardPart: SET131843

18″W × 18″ – 20″D ................... StandardPart: SET131844

20″W × 18″ – 20″D ................... StandardPart: SET131845

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!

CAPTAIN SEATINGREQUIRED for JELITEES-P 2S-P-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.

16″W × 16″D ...................................$450Part: SETASMB2770

16″W × 18″D ...................................$450Part: SETASMB2771

18″W × 16″D ...................................$450Part: SETASMB2775

FDA Class II Medical Device*

Comfort Seat Armrests (Flip-up, Height-Adjustable, Full-Length)

Deluxe Contour Armrests (Flip-up, Height-Adjustable, Full-Length)

Deluxe Contour, Limited Recline, High Back, with Solid Seat PanAdditional lead time may apply.

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

Elevating Leg Rests

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 above.

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.

Depth-Adjustable, Comfort Seat, Limited Recline, High Back, with Solid Seat Pan16″W × 16″ – 18″D ..........................................................StandardPart: SET145814

18″W × 18″ – 20″D ..........................................................StandardPart: SET145815

SOLID SEAT PAN SEATINGREQUIRED for JELITEES-P 2S-P-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 Solid Seat Pan Seating.)

Residual Limb Support, Left .......................................$325 ea.Part: FRMASMB5301. HCPCS: E1020

Residual Limb Support, Right ....................................$325 ea.Part: FRMASMB5300. HCPCS: E1020

Heel Loops (pair) for Swing-Away Leg Rests ...................$50Part: FRMASMB7873. HCPCS: E0951

Heel Loops (pair) for Elevating Leg Rests ........................$50Part: FRMASMB1503. HCPCS: E0951

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

16″W × 16″D ....................................................................... $450Part: SETASMB3178

16″W × 18″D ....................................................................... $450Part: SETASMB3179

18″W × 18″D ....................................................................... $275Part: SETASMB2848

18″W × 20″D ..................................................................StandardPart: SETASMB3182

20″W × 18″D ..........................................................................$275Part: SETASMB3184

20″W × 20″D ..........................................................................$275Part: SETASMB3185

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50″ Lap Belt ......................................................................$39.90Part: ACCBELT1000

70″ Lap Belt .......................................................................$39.90Part: ACCBELT1003

80″ Lap Belt.......................................................................$39.90Part: ACCBELT1004

90″ Lap Belt ......................................................................$39.90Part: ACCBELT1001

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

ACCESSORIESOptional.

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

JOYSTICK MOUNTING BRACKETSOptional. The power chair comes standard with an in-line joystick mounting bracket. An additional bracket 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

BACK-MOUNTED ACCESSORIESOptional. Only one back-mounted accessory can be used at a time. Includes mounting bracket and hardware.

Rear Basket (15.25″ × 9.75″ × 9.5″) for Deluxe Contour Seats ..$118Part: 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

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

Cup Holder, Style C, for Comfort Seats .............................$20Part: ACCASMB2288

Cup Holder, Style B, for Deluxe Contour Seats ................$20Part: ACCASMB2287

Flag Holder, for Comfort Seats ...........................................$25Part: ACCASMB2629

Flag Holder, for Deluxe Contour Seats ..............................$25Part: ACCASMB1930

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

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

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

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

UNOCCUPIED TIE-DOWN KITOptional. Applies only to Comfort Seats — see SEATING on Pages 1-2.

Unoccupied Tie-Down Kit .................................................................................................................................................................... $100Part: KIT1805521

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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: prideorders@pridemobility.com

© 2020 Pride Mobility Products Corp. All rights reserved.

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NOTES

*Jazzy® Power Chairs are FDA Class II Medical Devices designed to aid individuals with mobility impairments.