Citation Nr: 1018043 Decision Date: 05/14/10 Archive Date: 05/26/10 DOCKET NO. 09-00 649 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to an increased rating for posttraumatic stress disorder (PTSD), currently evaluated as 30 percent disabling. REPRESENTATION Appellant represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD Siobhan Brogdon, Counsel INTRODUCTION The Veteran served on active duty from August 1967 to August 1969. This appeal comes before the Department of Veterans Affairs (VA) Board of Veterans Appeals (Board) from an August 2007 rating decision of the VA Regional Office (RO) in Waco, Texas that denied an evaluation in excess of 30 percent for PTSD. Following review of the record, the appeal is REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. VA will notify the appellant if further action is required. REMAND The record reflects that the Veteran was afforded a VA examination for compensation and pension purposes in March 2009. During the course of the evaluation, he stated that he was not working and received Social Security disability. The Court of Appeals for Veterans Claims (Court) has held that VA must obtain Social Security Administration decisions and records which may have a bearing on a veteran's claim. See Waddell v. Brown, 5 Vet. App. 454 (1993); Clarkson v. Brown, 4 Vet. App. 565 (1993); Shoemaker v. Brown, 3 Vet. App. 519 (1993). Therefore, the Veteran's Social Security disability records should be requested and associated with the claims folder. Review of the claims folder indicates that the appellant receives ongoing treatment for psychiatric symptomatology. In October 2008 correspondence, he stated that he receives treatment at the Longview [Texas] VA outpatient facility. The Board notes that the most recent records date through January 2009. As there is constructive notice of the existence of additional VA records, they must be retrieved and associated with the other evidence on file. See Bell v. Derwinski, 2 Vet. App. 611 (1992); see also Epps v. Brown, 9 Vet. App. 341 (1996); Robinette v. Brown, 8 Vet. App. 69 (1995). Therefore, VA records dating from February 2009 should be requested from Longview VA and associated with the claims folder. The Board observes that a February 2009 psychological report received from Dr. Jereb in November 2009 reflects significant changes from the one received by him in May 2009, and also differs substantially from the VA examination findings in March 2009, particularly in the General Assessment of Functioning (GAF) score. Dr. Jereb more recently paints a more marked disability picture from that portrayed less than a year before. Therefore, in order to reconcile the conflicting findings, the Board is of the opinion that the Veteran should be afforded a current VA examination to ascertain the current status of the service-connected PTSD. Accordingly, the case is REMANDED for the following actions: 1. The RO should contact the Social Security Administration and obtain a copy of the Agency decision in the Veteran's case, and the medical documentation relied upon for the award of disability benefits. 2. VA outpatient records dating from February 2009 should be retrieved from the VA Longview clinic and associated with the claims folder. 3. After a reasonable period of time for receipt of the above- requested information, the Veteran should be afforded a comprehensive VA psychiatric examination to determine the current status of the service-connected PTSD. The claims folder should be made available to the examiner for review prior to the examination. All necessary tests and studies, including appropriate psychological studies, if indicated, should be conducted in order to identify the degree of social and occupational impairment attributable to PTSD. The clinical findings should be delineated in detail. The examiner should also provide a full multi-axial evaluation, to include the assignment of a numerical score on the GAF scale. An explanation of the significance of the assigned numerical score relative to the appellant's ability to work should be provided. The examiner is asked to address the specific criteria for mental disorders under 38 C.F.R. § 4.125 through § 4.130 (2009) (to be provided by the RO) and identify those criteria met by the Veteran, to include whether the appellant has deficiencies in each of the following areas: work, school, family relations, judgment, thinking, and mood due to PTSD. 4. After taking any further development deemed appropriate, the RO should re-adjudicate the issue on appeal. If the benefit is not granted, the appellant and his representative should be provided a supplemental statement of the case and afforded an opportunity to respond before the case is returned to the Board for appellate disposition. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2009). _________________________________________________ E.I. VELEZ Acting Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2009).