Citation Nr: 18150395 Decision Date: 11/15/18 Archive Date: 11/15/18 DOCKET NO. 16-49 060 DATE: November 15, 2018 REMANDED Entitlement to service connection for multiple sclerosis is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Navy from July 1986 to July 1990. Entitlement to service connection for multiple sclerosis is remanded. First, in August 2017 correspondence the Veteran provided a letter indicating that he is in receipt of Social Security Administration (SSA) disability benefits. These records have not been associated with the claims file and as such there may be outstanding and relevant SSA records. A remand is required to allow VA to request these records. Next, a private opinion from the Veteran’s treating physician in January 2016 notes ongoing treatment for his relapsing remitting multiple sclerosis since April 2007. These are potentially relevant outstanding private treatment records. A remand is required to allow VA to obtain authorization and request these records. In addition, the Board cannot make a fully-informed decision on the issue of service connection for multiple sclerosis because no VA examiner has opined as to direct and/or presumptive service connection. As such a remand is warranted. The matter is REMANDED for the following action: 1. Obtain the Veteran’s federal records from the Social Security Administration (SSA). Document all requests for information as well as all responses in the claims file. 2. Ask the Veteran to complete a VA Form 21-4142 to obtain clinical records from Connecticut Neurological Specialist, Dr. Hamid R. Sami, and for any additional relevant private treatment providers. Make two requests for the identified and authorized records, unless it is clear after the first request that a second request would be futile. 3. Then after completing the directives above, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his multiple sclerosis. The examiner must opine whether: (a.) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran’s multiple sclerosis is caused by an in-service injury or disease? (b.) Is it at least as likely as not that the Veteran’s multiple sclerosis (1) began during active service, (2) manifested within the applicable presumptive period after discharge from service, or was noted during service with continuity of the same symptomatology since service? Review of the entire claims file is required. The examiner must provide a complete rationale for all findings and opinions, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Attention is invited to the January 2016 and March 2016 private opinions noting the Veteran was first diagnosed with multiple sclerosis and optic neuritis in 1999, and he experienced on and off symptoms of multiple sclerosis since 1993. In addition, attention is invited to the Veteran’s and associated statements reporting he experienced right side, knee and toe pain and numbness directly after service. J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Kardian