Citation Nr: 18152521 Decision Date: 11/23/18 Archive Date: 11/23/18 DOCKET NO. 14-33 775 DATE: November 23, 2018 REMANDED Entitlement to an initial disability rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1967 to February 1969, to include service in the Republic of Vietnam from August 1967 to January 1968. He was awarded the Bronze Star Medal with “V” Device and the Combat Infantryman’s Badge. Upon review, remand is required to obtain outstanding VA treatment records and to attempt to obtain potentially outstanding Vet Center records. The Veteran submitted a February 2013 VA Form 21-4142 (Authorization and Consent to Release Information to the [VA]), on which he referenced mental health treatment from November 2012 to the present at the VA Oceanside facility. In a later February 2013 statement, the Veteran stated that “I also have medical evidence at the VA[outpatient clinic] in Oceanside, CA., related to my PTSD.” The February 2014 VA PTSD Disability Benefits Questionnaire (DBQ) referenced the Veteran as having a mental health “intake at the Oceanside Clinic in December 2012” and an August 2013 list of VA appointments listed a December 2012 PTSD orientation. The March 2014 rating decision on appeal listed under the evidence heading “VA outpatient treatment reports, San D[ie]igo, CA. VA Medical Center, from November 16, 2011 through February 25, 2014; reviewed electronically.” The July 2014 statement of the case (SOC) listed as evidence VA treatment records for the same dates. Upon review of the evidence of record, complete VA treatment records for this time period are not of record. The only VA treatment records of record obtained prior to the July 2014 SOC were limited to the period from November 2011 to May 2012. VA treatment records obtained by VA after the July 2014 SOC appear complete from November 2017 to April 2018, but not for the period prior to November 2017. The additionally obtained VA treatment records do not include mental health records from November 2012 to 2013, as referenced by the Veteran and other evidence of record discussed above. As such, remand is required to obtain outstanding VA treatment records. VA’s duty to assist includes obtaining adequately identified VA treatment records. See 38 U.S.C. § 5103A(c)(1)(B); 38 C.F.R. § 3.159(c)(3); see also Sullivan v. McDonald, 815 F.3d 786 (Fed. Cir. 2016) (stating that “[w]e hold that [38 C.F.R] § 3.159(c)(3) extends the VA’s duty to assist to obtaining sufficiently identified VA medical records…regardless of their relevance”). The Veteran in February 2013, via his statement and the VA Form 21-4142, identified VA mental health treatment and such records are not of record. In addition, the Agency of Original Jurisdiction (AOJ) listed as evidence records from this time period, which, as noted, are not of record. The Board has therefore not been able to review the same record that the AOJ reviewed, which raises due process concerns. See generally 38 U.S.C. § 7104(a) (stating that “[a]ll questions in a matter which…is subject to decision by the Secretary shall be subject to one review on appeal to the Secretary”). Accordingly, VA must associate with the Veteran’s electronic claims file complete VA treatment records from the San Diego VA system from May 2012 to November 2017 and from April 2018. In addition, an unrelated May 2018 rating decision listed under the evidence heading “VA treatment reports from VAMC Honolulu for the period from March 3, 2015 through November 23, 2016.” No such records are of record and therefore on remand complete VA treatment records from the Honolulu VA system must be obtained. In addition, while some Vet Center treatment records are of record, other records may be outstanding. Of record are San Marcos Vet Center records from January 2013 to July 2013. The April 2014 VA PTSD DBQ referenced that the Veteran “has been to one meeting” at the Vet Center “since returning to Califo[rnia] recently.” Also, a January 2018 VA treatment record stated that the Veteran “elected to be seen at the [San Marco] Vet Center.” A March 2018 VA PTSD DBQ, however, stated that the Veteran “used to attend counseling at the San Marcos Vet Center…[Veteran] has not attended counseling for the past couple of years.” As such, on remand, VA must take appropriate action to attempt to obtain any outstanding Vet Center records, to include requesting a release from the Veteran for such records. Finally, the Veteran submitted in March 2012 a typed multi-page statement that had the pages numerically labeled. Based on these labels, page four appears to be missing. At the end of page three, the Veteran was referencing psychiatrist treatment, so page four may have contained information relevant to the Veteran’s PTSD at issue in this appeal. The Veteran and his representative are advised that they may submit the referenced outstanding page. The matter is REMANDED for the following action: 1. Obtain outstanding VA treatment records. This includes: (a.) Complete records from the San Diego VA system from May 2012 to November 2017 and from April 2018. (b.) Complete records from the Honolulu VA system. 2. Ask the Veteran to complete the appropriate release necessary to obtain Vet Center treatment records. If authorization is received, obtain any records available. J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Hoopengardner, Counsel