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Jazzy Elite 14 2S-C ......................................................... $5,099Part: JELITE14 2S-C. HCPCS: K0823Captain Seating

Jazzy Elite 14 2S-SS ....................................................... $5,099Part: JELITE14 2S-SS. HCPCS: K0822Solid Seat Pan Seating

Jazzy® Elite 14 Order Form, Quick Ship

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

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 RedPart: SHDASMB7120084

Jazzy BluePart: SHDASMB7120085

BASE COLORREQUIRED. Select one 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-elite-14.

Standard Features• Front-wheel drive• Angle-adjustable foot platform• Flat-free tires

• In-line joystick mounting bracket • 5-amp off-board charger• 50-amp Dynamic Shark joystick

18″W × 18″ – 20″D ....................StandardWith 60″ lap belt Part: SETASMB6895

20″W × 18″ – 20″D ....................StandardWith 60″ lap beltPart: SETASMB6896

22″W × 20″ – 22″D ...................StandardWith 70″ lap beltPart: SETASMB6897

16″W × 16″D ........................................................................................................................................................................................... $450With 60″ lap belt Part: SETASMB2770

SEATINGREQUIRED. Select one seat. Seats come with a lap belt. See Page 2 for solid seat pan seating.

Captain Seating (Depth-Adjustable, Fold Flat, Limited Recline, High Back)

Captain Seating (Limited Recline, High Back)

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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 Rests with 7.25″ × 6″ Foot Plates (pair) ..... $325Part: FRMASMB3810. HCPCS: K0195

Elevating Leg Rests with 8.5″ × 6″ Foot Plates (pair) .... $325Part: FRMASMB3806. 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

BATTERIESREQUIRED. The Power Chair requires two batteries. The batteries are automatically selected with a Quick Ship order.

NF-22, 55Ah .................................................................................................................................................................................... $330 ea.Part: BATLIQ1018. HCPCS: E2361

ACCESSORIESOptional. See Page 3 for back-mounted accessories.

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

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

Bell-Shaped Foot Platform ..........$235Part: RIGASMB7120041

Foot Platform Bracket ..................... $50Height-AdjustablePart: ACCASMB2580

Dynamic Programmer ..................$650Part: ELEASMB4352

Cup Holder, Style B ........................$20Part: ACCASMB2287

Flag Holder ......................................$25Deluxe Contour part: ACCASMB1930Depth-adjustable part: ACCASMB1907

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

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

Flip-up, Height-Adjustable, Full-Length Armrests .................................................................................................................$85 ea.Left part: FRMASMB8614. Right part: FRMASMB8615. HCPCS: E0973

ARMRESTSREQUIRED. The armrests are automatically selected with a Quick Ship order.

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.

SEATING ContinuedREQUIRED. Select one seat. Seats come with a lap belt.

*16″W × 16″D .................................. $450With 60″ lap beltPart: SETASMB3178

*16″W × 18″D .................................. $450With 60″ lap beltPart: SETASMB3179

18″W × 18″D ............................StandardWith 60″ lap beltPart: SETASMB2848

18″W × 20″D ............................StandardWith 60″ lap beltPart: SETASMB3182

*20″W × 18″D .................................. $450With 60″ lap beltPart: SETASMB3184

*20″W × 20″D .................................. $450With 60″ lap beltPart: SETASMB3185

Solid Seat Pan Seating (Deluxe Contour, Limited Recline, High Back)Additional lead time may apply.*

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: _____________________________________

JOYSTICK MOUNTING BRACKETSOptional. The power chair comes with an in-line joystick mounting bracket. Additional brackets may be selected below.

Swing-Away JoystickIn-line Mount (Right)

Swing-Away JoystickOffset Mount (Right)

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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REFERENCE ORDER FORMSOptional. Select below to note that additional order forms will accompany this order form.

Special Measurement Seat

SPECIAL MEASUREMENT SEATOptional. Special measurement seats are not available as a Quick Ship order. Seat size cannot exceed 22″W × 22″D. Contact your inside sales specialist for pricing.

Width:______ Depth:______ Seat Type:_______________

Swing-Away, In-line ..................................................... $245Left part: ACC148368. Right part: ACC148369HCPCS: E1028

Swing-Away, 1″ Offset ................................................. $245Left part: ACC148370. Right part: ACC148371HCPCS: E1028

ADDITIONAL LAP BELTSOptional. Seats come with a 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

See cushion order form Synergy Seat (Not a Quick Ship option)

Rear Basket (15.25″ × 9.75″ × 9.5″) ......................................$118 Deluxe Contour part: ACCASMB1914 Depth-adjustable part: FRMASMB1280

Cane/Crutch Holder ............................................................$110Deluxe Contour part: ACCASMB2294Depth-adjustable part: FRMASMB1270. HCPCS: E2207

Walker Holder ......................................................................$103Deluxe Contour part: ACCASMB2541Depth-adjustable part: FRMASMB1271

Oxygen Tank Holder ...........................................................$118Deluxe Contour part: ACCASMB2292Depth-adjustable part: FRMASMB1269. HCPCS: E2208

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