Citation Nr: 18142795
Decision Date: 10/16/18	Archive Date: 10/16/18

DOCKET NO. 16-33 289
DATE:	October 16, 2018
REMANDED
Entitlement to service connection for traumatic brain injury (TBI) is remanded.
REASONS FOR REMAND
The Veteran served on active duty from September 1967 to July 1969.  This matter is on appeal from an August 2015 rating decision.  
In the August 2015 rating decision, the RO adjudicated several issues, including denials of service connection for TBI and service connection for left basilar artery ischemic stroke.  In August 2015, the Veteran submitted a notice of disagreement (NOD) regarding these two issues, and a statement of the case (SOC) was issued addressing the issues in July 2016.  However, on his July 2016 substantive appeal (VA Form 9), the Veteran specially stated that he was only appealing the issue of service connection for TBI.  Therefore, the issue of entitlement to service connection for left basilar artery ischemic stroke is not in appellate status, and will not be addressed by the Board.
Service connection for TBI 
In an April 2014 Report of General Information, the Veteran indicated that he was being treated by a private physician.  On a VA Form 21-8940 submitted in May 2014, the Veteran identified a Dr. V.I. as his doctor and that he was attending bi-monthly appointments.  Also, in May 2014, the Veteran submitted copies of November 2004 treatment records from UNC Health Care, which indicated that he was to return for follow-up care, but no further records are in the claims file.   
It does not appear from the available evidence that any efforts have been made to obtain private treatment records from these private phsyicians and facilities.  Because such records, if obtained, might contain information bearing on the Veteran’s appeal, efforts should be made to procure them.  See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c).  A remand is required to allow VA to obtain authorization and request these records. 
Additionally, the end of the June 2015 VA TBI examination report refers to a separate Mental Health Compensation and Pension note dated June 1, 2015.  It does not appear that this note is associated with the claims file, and the opinion provided in June 2015 appears to be based at least in part on the June 1, 2015 note.  Thus, this record should be associated with the claims file on remand.  
The matter is REMANDED for the following actions:
1.  Contact the Veteran and afford him the opportunity to identify or submit any additional pertinent evidence in support of his claims, to include records from Dr. V.I., UNC Health Care, and any private treatment providers who have treated him for a TBI.  
Based on the response received, attempt to procure copies of all records which have not previously been obtained from identified treatment sources. 
2.  Associate with the claims file a copy of the Mental Health Compensation and Pension note dated June 1, 2015, referred to in the June 2015 VA TBI examination, and any other outstanding VA treatment records.
3. Conduct any other development needed as a result of the development requested above, including obtaining a new examination or opinion, if deemed necessary. 
 
M. SORISIO
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	Bonnie Yoon, Counsel