Citation Nr: 18141083 Decision Date: 10/09/18 Archive Date: 10/09/18 DOCKET NO. 15-00 534 DATE: October 9, 2018 REMANDED Entitlement to service connection for posttraumatic stress disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1986 to June 1988. In June 2018, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge (VLJ). A copy of the hearing transcript has been associated with the electronic file. Entitlement to service connection for posttraumatic stress disorder is remanded. The Veteran contends that his PTSD is related to an in-service physical assault. At the Veteran’s hearing in June 2018, he testified that he was currently receiving treatment for PTSD. A review of the electronic file reveals that the most recent medical records associated with the file are dated November 2012. On remand all relevant VA treatment records from November 2012 to date should be obtained and associated with the file. Additionally, the Board notes that a review of the file shows the Veteran was not provided adequate notice of the evidence necessary to substantiate such a claim for PTSD based on an in-service personal assault as required by 38 C.F.R. § 3.304(f)(5). VA will not deny a PTSD claim that is based on in-service personal or sexual assault without first advising the claimant that alternative evidence from sources other than the Veteran’s service records or evidence of behavior changes may constitute credible supporting evidence of the stressor. The Veteran should also be afforded the opportunity to furnish this type of evidence or advise VA of potential sources of such evidence. 38 C.F.R. § 3.304 (f)(5). Therefore, a remand is necessary to ensure that the Veteran is provided a proper notice letter for his PTSD claim based on an in-service personal assault. The matter is REMANDED for the following action: 1. Obtain all outstanding, pertinent VA treatment records and associate them with the electronic file. If any identified records are not obtainable (or none exist), the Veteran and his representative should be notified and the record clearly documented. 2. Provide the Veteran an opportunity to submit any outstanding private treatment records relating to his claimed PTSD. Provide the Veteran with the appropriate authorization for release form(s). For any outstanding private treatment records identified and authorized by the Veteran, make at least two (2) attempts to obtain such records. All attempts made must be documented in the electronic file, to include the unavailability of any identified records. For any identified records that are not obtained, notify the Veteran and his representative of such and provide him with an opportunity to submit those records directly. 3. Send the Veteran a notice letter in connection with his claim for service connection for PTSD based on in-service personal assault trauma. The letter should (1) inform him of the information and evidence that is necessary to substantiate the PTSD claim based on personal assault; (2) inform him of the information and evidence that VA will seek to provide; and (3) inform him of the information and evidence he is expected to provide. Specifically, this letter should comply with 38 C.F.R. § 3.304(f)(5) and advise the Veteran of specific examples of alternative forms of evidence to corroborate his account of in-service personal assault and that behavioral changes may constitute credible supporting evidence of the stressor. This letter should also include a VA Form 21-0781a (Statement in Support of Claim for PTSD Secondary to Personal Assault). Based on the information provided by the Veteran, conduct any additional development that may be necessary to verify the Veteran’s alleged personal assault stressor(s). 4. Upon completion of the above, if there is enough corroborating evidence to suggest that the claimed in-service stressor of personal assault may have occurred, schedule the Veteran for a VA examination with an appropriate professional. The electronic file and a copy of this Remand must be made available to the examiner. The examiner should note in the examination report that the electronic file and the Remand have been reviewed. All indicated tests and studies should be accomplished and the findings then reported in detail. The examiner should review any new evidence received, and should address the Veteran’s contention that his PTSD is due to an in-service personal assault. The examiner should determine whether it is at least as likely as not that the Veteran displayed any behavior in service that would be consistent with his claim of personal assault while on active duty. a) If the examiner is of the opinion that a personal assault occurred, the examiner should then state whether the Veteran meets the criteria for a diagnosis of psychiatric disorder, to include PTSD b) If a diagnosis of PTSD is deemed appropriate, is it at least as likely as not (a 50% or higher degree of probability) that it is causally related to his reported stressors during service, to include a personal assault? The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of the conclusion as it is to find against it. G. A. WASIK Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. M. Lunger, Associate Counsel