Citation Nr: 18154973 Decision Date: 12/04/18 Archive Date: 12/03/18 DOCKET NO. 16-57 817 DATE: December 4, 2018 REMANDED Entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from August 1969 to March 1971. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona. The Veteran is seeking entitlement to service connection for a psychiatric disorder, to include PTSD. He contends that he has PTSD resulting from “go[ing] into the Army and fight[ing] a war at 19 years old.” The Veteran further claims that he had his whole life taken away from him when he went to war and that he had never had anything affect him as profoundly as “living in a war zone.” In July 2015, the Veteran underwent a VA psychiatric examination. After reviewing the electronic claims file and evaluating the Veteran, the VA examiner opined that the Veteran does not have a clinically diagnosed mental health disorder and that his symptoms (primarily documented as anxiety) do not meet the diagnostic criteria for PTSD under the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). In his November 2016 substantive appeal to the Board (VA Form 9), the Veteran stated, “On November 15, 2016, I had a video conference with Dr. Kent, [a] psychiatrist with the VA. I spent approximately one hour discussing my symptoms and concerns of what I feel is PTSD. In conclusion of the interview, Dr. Kent said I have all the symptoms of PTSD.” The Board has reviewed the evidence of record and does not find any VA medical records associated with the electronic claims file in November 2016. In fact, the only pertinent medical evidence of record regarding the Veteran’s claim is the July 2015 VA psychiatric examination report. When put on notice of the existence of private or VA medical records, VA must attempt to obtain those records before proceeding with the appeal. See 38 C.F.R. § 3.159(c)(1); Lind v. Principi, 3 Vet. App. 493, 494 (1992); Murincsak v. Derwinski, 2 Vet. App. 363 (1992). It does not appear that the report cited by the Veteran has been associated with his electronic claims file. The Veteran suggests that the findings of that medical report will help substantiate his claim for service connection. As such, the RO must attempt to obtain this report, along with any VA treatment records documenting treatment of a psychiatric disorder if they are available. This matter is REMANDED for the following actions: 1. Contact the Veteran and ask him to identify whether there are any outstanding VA or private medical records reflecting treatment for his claimed psychiatric disorder, to include PTSD. If such records are identified, then obtain those records and associate them with the electronic claims file. To expedite this action, the Veteran is encouraged to submit any additional VA or private medical records in his possession, including the one cited above. Regardless of the Veteran’s response, the RO should attempt to obtain any available VA treatment records, including the following report referenced by the Veteran in his November 2016 substantive appeal to the Board (VA Form 9): a November 15, 2016 psychiatric evaluation report from a VA psychiatrist named Dr. Kent that may provide a diagnosis of PTSD. 2. If VA treatment records are obtained, the RO should carefully review those records. If any records document a clinical diagnosis of a psychiatric disorder, to include PTSD, the RO should take appropriate action to further develop the claim on appeal and ensure that VA’s duties to notify and assist have been met. This includes verifying any alleged stressor(s) and providing the Veteran with a VA psychiatric examination if appropriate. JOHN J. CROWLEY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. L. Marcum, Counsel