Medical POA Lillie Wynn .pdf
Jackson Mortgage Consulting, LLC, Petitioner V City Of Detroit, Respondent · 25-003290-TT
Text extracted from the reviewed PDF, organized by page. OCR and reading order may contain errors; confirm details in the PDF below.
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MEDICAL POWER OF ATTORNEY
IMPORTANT INFORMATION
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IN TRT YOU REVIEW THE FOLLOWING INFORMATION BEFORE YOU SIGN
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{ENT. READ THE INFORMATION CAREFULLY AND SEEK GUIDANCE FROM A
ems rR PROFESSIONAL OR ATTORNEY IF YOU DO NOT UNDERSTAND ANY OF
By Signing this document, you are giving authority to the person you are designating as your agent to
make medical decisions on your behalf. Medical decisions can include any medical service, treatment,
medical procedure, diagnosis or treat both mental and physical conditions. Your agent will be able to
aa with the same authority you would have if you were able to act for yourself and will have the
authority to consent and refuse to consent to medical treatment including decisions about
withdrawing or withholding life-sustaining treatment. It is, therefore, important that you know and
must your agent and that your agent is aware of your preferences for healthcare treatment.
Even after you sign this document, you will still be able to make your healthcare decisions assuming
you are still considered mentally competent. Your agent cannot act on your behalf until your physician
has determined that you are no longer physically or mentally able to make medical decisions unless
otherwise stated in this document.
The person you choose as your agent must be at least 18 years old and someone that you trust with your
healthcare. Your agent is not liable for any decisions they make on your behalf, as long as those
decisions were made in good faith. You should make sure that you have chosen an agent who wants to
take on the role of agent. Discuss your medical preferences with your agent so they are aware of your
wishes. Review this document with your agent so they are aware of their role. You also may choose up
to two alternate agents in case your main agent is unavailable to act. Your alternate agent(s) should also
be over 18 and aware of your preferences.
You may revoke this document at any time while you are still competent to do so. You may revoke it by
telling your medical provider and your agent that you are revoking the document or you may provide
them a written revocation (recommended). If you execute another power of attorney later, that will
have the effect of revoking this one.
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L, Lillie B Wynn, of 4196 W Outer Drive, Detroit, Michigan, 48221 (hereinafter known as the “Principal ) hereby appoint Thadaus S Jackson of 4196 W Outer Drive, Detroit, Michigan, 48221 (hereinafter known as the “Agent”) as my Agent to make any and all medical decisions on my behalf, except to the extent that I limit in this document. My Agent can be reached at the following contact information: Phone number: (720) 499-7205 Email address: tjpinnocle@gmail.com 0 F RN, AGE S 1f my Agent appointed above is unable or unwilling to serve, I appoint the following person(s) to serve as Agent(s) in the order set forth below with the authority to make health care decisions on my behalf as provided herein: Alternate Agent #1 Bemetta A Kyles-Hankins of 4196 W Outer Dr, Detroit, Michigan, 48221 can be best reached at the following phone number: (313) 717-4477. If my main Agent, Thadaus S J ackson, and Alternate Agent #1, Bernetta A Kyles-Hankins, are unable or unwilling to serve, there shall be no other individuals authorized to make medical decisions on my behalf. : LIMITATIONS OF AGENT Initial BY) - The Agent shall not have any limitations to the medical decision making powers they may make on my behalf. Therefore I acknowledge that the Agent shall have the right to provide, withhold, or withdraw artificial nutrition and hydration and all other forms of health care to keep me alive. ) FIN - I intend for my Agent to be treated as I would with respect to my rights regarding the use and disclosure of my individually identifiable health information or medical records. This release authority applies to information governed by the Health Insurance Portability and Accountability Act (HIPAA) of 1996, 42 USC 1320d, 45 CFR 160-164. DURATION Unless stated otherwise herein, this document shall remain in effect until I revoke it. I understand that I cannot revoke this document if I am considered incompetent to make my own decisions. Initial Page 2
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\ nN - This document shall not have an end date and shall terminate upon revocation, a new medical power of attomey, or my death. WHEN MY AGENT'S AUTHORITY BECOMES EFFECTIVE My Agent's authority becomes effective: Initial Lou - Immediately to make health care decisions on my behalf. AGENT'S OBLIGATION My Agent shall make healthcare decisions for me in accordance with this power of attorney for healthcare, any instructions I give in Part II of this form, and my other wishes to the extent known to my Agent. To the extent my wishes are unknown, my Agent shall make healthcare decisions for me in accordance with what my Agent determines to be in my best interest. In determining my best interest, my Agent shall consider my personal values to the extent known to my Agent. AGENT'S POST- ORITY Initial Lu - My Agent is authorized to make anatomical gifts, authorize an autopsy, and direct disposition of my remains, except as I state here or in Part 3 of this form. PRIOR MEDICAL POWER OF (0) Y By signing this document, I hereby revoke any and all prior medical powers of attorney that I may have executed. PART II. LIVING WILL Initial ¥ oy, -1, Lillie B Wynn, declare to include this Living Will as part of my Medical Power of Attomney Form. -OF- SI 1 direct that my healthcare providers and others involved in my care provide, withhold, or withdraw treatment in accordance with the choice I have initialed below: Initial Page 3 a a J er EE
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Lu) - I choose not to prolong life if I have an incurable and irreversible condition that will result in my death within a relatively short time, or if I become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, or the likely risks and burdens of treatment would outweigh the expected benefits. RELIEF FROM PAIN Initial LoS - With regard to pain, I direct that treatment for alleviation of pain or discomfort be provided at all times, even if it hastens my death. OTHER WISHES Initial Les. - I would like to add the following: Absolutely no blood transfusions or blood fractions of any kind, under any circumstances, are to be administered to me. Alternative methods are acceptable and must be discussed with my representative under this Power of Attorney. PART ITI. DONATION OF ORGANS Initial Law. 1 do not wish to donate any of my organs after my death. PART IV. PRIMARY CARE PHYSICIAN L, Lillie B Wynn, do not wish to enter my Primary Care Physician's information. ORIGINAL AND COPIES OF THIS DOCUMENT This original document and/or copies shall be kept at the following locations: Copies will be held with my other daughter, Bernetta A Kyles-Hankins, and various Hospitals or Physicians as necessary. GO ING L This document shall be governed under the laws in the State of Michigan. EXECUTION Principal’s Signature Ld le. 2 . Lh ae, Lillie B Wynn +. Page 4
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Agent’s Signa Thadaus S Jackson Page 5
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WITNESS STATEMENT & ACKNOWLEDGMENT Iam not the person appointed as agent or successor agent in this medical power of attorney. I am not related to Lillie B Wynn by blood or marriage. I am not entitled to any portion of their estate, nor do I have any claim against their estate. I am not the attending physician of Lillie B Wynn or an employee of the attending physician. I am not involved in providing direct patient care to Lillie B Wynn and not an officer, director, partner, or business office employee of the healthcare facility or of any parent organization of the healthcare facility. WITNESS #1 Signature: 22, /.. pAZZ Print Name: 37 24 Corttny | Date: & “8 -2°2% Address: 2-9 920 Grand parc Qr wo rlew m=gfeq> ‘WITNESS #2 isd Print Name: Lewy fore Date: WH, [fois nites: [7678 ire SF. LeAboi lM #5234 Page 6