Jazzy Passport Order Form - Pride MobilityTitle: Jazzy Passport Order Form Subject: Jazzy Passport...
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Page 1 of 2 INFINFB4214/RevA/23JAN2020 Jazzy ® Passport — Quick-Ship Order Form Account Number: ___________ Date: ________________ Provider Name: __________________________________ Contact: ________________________________________ Phone: ___________________ Fax: _________________ Email:__________________________________________ PO Number:_____________________________________ Marked for: _____________________________________ Ship to Address: _________________________________ City: _____________________ State: ______ Zip: ______ INTRODUCTION 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 Service for accurate parts ordering. Thank you for choosing Pride Mobility Products! Pride ® Mobility Products Corporation 182 Susquehanna Ave., Exeter, PA 18643 Phone: 1-800-800-8586 | Fax: 1-800-800-1636 | Email: [email protected] Jazzy Passport Part: FJPTBK1700 HCPCS: K0899 — Power mobility device, not coded by DME PDAC or does not meet criteria. Select one option below: Jazzy Passport (FJPTBK1700) with 18Ah Lithium-ion Battery (BAT1708123) ................................................. TOTAL MSRP $2,899 Jazzy Passport (FJPTBK1700) with 10.4Ah Travel* Lithium-ion Battery (BAT1802153) ................................. TOTAL MSRP $2,859 18Ah Lithium-ion Battery ..................................................$699 Part: BAT1708123-P 10.4Ah Travel* Lithium-ion Battery ..................................$649 Part: BAT1802153-P BASE MODEL REQUIRED. Select a power base. 250 lb. weight capacity. Find more details and specifications at pridemobility.com/c/jazzy-power-chairs. ADDITIONAL BATTERY PACKS REQUIRED. Select one battery. Standard Features • VSI controller • Mesh cushion • Mesh cup holder • Storage bag *Note: Transport of this item on commercial aircraft is subject to federal regulations and airline policy. Please consult your airline prior to your flight to ensure your Jazzy Passport and its lithium-ion batteries are permitted. XLR USB Charger ................................................................................................................................................................................... $38 Part: ACC1704791 ACCESSORIES Optional.
Transcript of Jazzy Passport Order Form - Pride MobilityTitle: Jazzy Passport Order Form Subject: Jazzy Passport...
Page 1 of 2INFINFB4214/RevA/23JAN2020
Jazzy® Passport — Quick-Ship Order FormAccount Number: ___________ Date: ________________
Provider Name: __________________________________
Contact: ________________________________________
Phone: ___________________ Fax: _________________
Email: __________________________________________
PO Number: _____________________________________
Marked for: _____________________________________
Ship to Address: _________________________________
City: _____________________ State: ______ Zip: ______
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. Pride Providers may contact Technical Service for accurate parts ordering.
Thank you for choosing Pride Mobility Products!
Pride® Mobility Products Corporation182 Susquehanna Ave., Exeter, PA 18643Phone: 1-800-800-8586 | Fax: 1-800-800-1636 | Email: [email protected]
Jazzy PassportPart: FJPTBK1700HCPCS: K0899 — Power mobility device, not coded by DME PDAC or does not meet criteria.
Select one option below:
Jazzy Passport (FJPTBK1700) with 18Ah Lithium-ion Battery (BAT1708123) ................................................. TOTAL MSRP $2,899
Jazzy Passport (FJPTBK1700) with 10.4Ah Travel* Lithium-ion Battery (BAT1802153) ................................. TOTAL MSRP $2,859
18Ah Lithium-ion Battery ..................................................$699Part: BAT1708123-P
10.4Ah Travel* Lithium-ion Battery ..................................$649Part: BAT1802153-P
BASE MODELREQUIRED. Select a power base. 250 lb. weight capacity. Find more details and specifications at pridemobility.com/c/jazzy-power-chairs.
ADDITIONAL BATTERY PACKSREQUIRED. Select one battery.
Standard Features• VSI controller• Mesh cushion
• Mesh cup holder• Storage bag
*Note: Transport of this item on commercial aircraft is subject to federal regulations and airline policy. Please consult your airline prior to your flight to ensure your Jazzy Passport and its lithium-ion batteries are permitted.
XLR USB Charger ................................................................................................................................................................................... $38Part: ACC1704791
ACCESSORIESOptional.
Page 2 of 2INFINFB4214/RevA/23JAN2020
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
Account Number: ___________ Date: ________________ Marked for: _____________________________________
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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