INFINFB3836/RevB/01FEB2019 Page 1 of 3

Jazzy Air® 2 Quick Ship Order Form

Pride® Mobility Products Corporation182 Susquehanna Ave. Exeter, PA 18643Phone: 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: ______

Jazzy Air® 2 ...................................................................... $5,799Part: JAIR21001

HCPCS: K0899 - Power Mobility Device, not coded by DME PDAC or does not meet criteria.

BASE MODELREQUIRED. Select a power base. 300 lb. weight capacity. More details and specifications can be found at pridemobility.com/jazzy_power_chairs.

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. Please contact technical service for accurate parts ordering.

Thank you for choosing Pride Mobility Products!

COLORREQUIRED. Colors shown here may differ from actual product depending on monitor/printer calibration used.

Ruby RedPart: DGN1803732

Pearl WhitePart: DGN1803736

Onyx BlackPart: DGN1803737

Sapphire BluePart: DGN1803734

Citrine YellowPart: DGN1803740

SilverPart: DGN1803739

Pink TopazPart: DGN1803741

Black Pearl*Part: DGN1803738

Tanzanite Blue*Part: DGN1803735

Garnet Red*Part: DGN1803733

*Matte Colors

SEATINGREQUIRED. Select only one seat with size.

16"W × 16" – 18"D .................. StandardPart: SET1701577With 60" Lap Belt

18"W × 18" – 20"D .................. StandardPart: SET1701578With 60" Lap Belt

20"W × 20" – 22"D .................. StandardPart: SET1701579With 60" Lap Belt

Captain Seating — Fold-Flat Seats

16"W × 16" – 18"D .................. StandardPart: SET1701580With 60" Lap Belt

18"W × 18" – 20"D .................. StandardPart: SET1701581With 60" Lap Belt

20"W × 20" – 22"D .................. StandardPart: SET1701582With 60" Lap Belt

Solid Seat Pan Seating — Fold-Flat Seats

Includes standard features:• Integrated foot platform• Flat-free drive wheels• VR2 joystick• In-line joystick

mounting bracket

• U-1 batteries with 5-amp charger

• LED marker lights• 12" seat elevation• Under-seat storage

https://www.pridemobility.com/c/jazzy-power-chairshttps://acrobat.adobe.com/us/en/acrobat/pdf-reader.html

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Account Number: ___________ Date: ________________ Marked for: _____________________________________

ADDITIONAL SHROUDSOptional. Reference colors shown on Page 1.

Ruby Red ...................................$127.37Part: DGN1803732

Pearl White ................................$127.37Part: DGN1803736

Onyx Black ................................$127.37Part: DGN1803737

Sapphire Blue ...........................$127.37Part: DGN1803734

Citrine Yellow ............................$127.37Part: DGN1803740

Silver ..........................................$127.37Part: DGN1803739

Pink Topaz .................................$127.37Part: DGN1803741

Black Pearl* ..............................$127.37Part: DGN1803738

Tanzanite Blue* ........................$127.37 Part: DGN1803735

Garnet Red* ..............................$127.37 Part: DGN1803733

*Matte Colors

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

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

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

Saddle Bag (11.75" × 17") ............... $35Part: DWR1020D016

Cup Holder — Style C ..................... $20Part: ACCASMB2288

Flag Holder ..................................... $25Part: ACCASMB2416

Cell Phone/Media Holder .............. $60Part: ACC1611300

ACCESSORIESOptional.

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") .....................................$118 Part: ACC1610772

Cane/Crutch Holder ............................................................$110Part: ACC1610775

Oxygen Tank Holder ...........................................................$118Part: ACC1610773

Walker Holder ......................................................................$103Part: ACC1610776

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

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

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

90" Lap Belt ............$39.90 Part: ACCBELT1005

Additional Lap BeltsOptional. The Jazzy Air 2 comes standard with a 60" lap belt. Additional sizes are available below.

40-Amp AGM ...................................................................................................................................................................................$175 ea. Part: BAT1704612

Battery UpgradeOptional. The Jazzy Air 2 comes standard with two U-1 batteries. Battery upgrade options are available below.

Joystick Mounting BracketOptional. The Jazzy Air 2 comes standard with an in-line joystick mount. An additional mount may be selected below.

Retract4 Swing-Away Joystick Mounting Bracket.......................................................................................................................... $350 Part: MEC168060

Match seat selection width and depth Non-matching cushion size, see cushion order form orcushion part number:

CUSHION QUICK PICKOptional. Refer to the specific cushion order form for detailed pricing, sizes, codes, and part numbers. Check the non-matching box and attach a cushion order form for a size other than the previously selected seat width and depth or enter part number below.

Cushion SelectionOptional. See cushion order form for detailed sizing and pricing.

Stealth Simplicity® G Cushion ................................ $110-$165(General Use)

Stealth Solution® Cushion SPP ..............................$375-$430(Skin Protection and Positioning)

Synergy Solution® 1 Cushion ................................. $430-$480(Skin Protection)

Stealth Spectrum® Gel Cushion SPP .................... $460-$530(Skin Protection and Positioning)

Stealth Spectrum® Foam Cushion SPP ................ $460-$590(Skin Protection and Positioning)

http://www.pridemobility.com/resourcecenter/downloads/order_forms/order_forms.asphttps://www.prideprovider.com/OA_HTML/xxprd_custom_build_forms.jsp

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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: prideorders@pridemobility.com

© 2019 Pride Mobility Products Corp. All rights reserved.

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NOTES

Account Number: ___________ Date: ________________ Marked for: _____________________________________

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Provider Name: Contact: PO Number 2: Ship to address 2: Email: City 2: State 2: Zip 2: Phone: Fax: base 3: Offcolor: Offseat: OffAccount Number: Date: Marked for: color 10: Offcolor 9: Offcolor 8: Offcolor 7: Offcolor 6: Offcolor 5: Offcolor 4: Offcolor 3: Offcolor 2: Offaccessories 10: Offaccessories c 15: Offaccessories c 16: Offaccessories c 14: Offaccessories b 10: Offaccessories a 13: Offaccessories a 12: Offrear access: Offlapbelts4: Offlapbelts 2: Offlapbelts3: Offlapbelts2: Offlapbelts7: Offlapbelts8: Offcushion quick: OffText Field 83: cushion select 16: Offcushion select 15: Offcushion select 14: Offcushion select 7: Offcushion select 6: Offbranch patch 26: Offbranch patch 25: Offbranch patch 24: Offbranch patch 23: Offbranch patch 22: Offbranch patch 21: OffText Field 82: