Citation Nr: 1817336 Decision Date: 03/19/18 Archive Date: 03/30/18 DOCKET NO. 08-01 766 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for hypertension. 2. Entitlement to recognition of L.K. as the "helpless child" of the Veteran on the basis of permanent incapacity for self-support prior to attaining age 18. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD S. Keyvan, Counsel INTRODUCTION The Veteran served on active duty from August 1968 to March 1970, with service in the Republic of Vietnam from March 1969 to March 1970. He also had subsequent service in the Alabama National Guard. This matter comes before the Board of Veterans' Appeals (Board) on appeal from the July 2009 and October 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. The July 2009 decision, in part, denied service connection for hypertension. In The October 2014 decision, the RO found that permanent incapacity for self-support was not established for the veteran's child, L.K. (noted on the title page of this decision as entitlement to recognition of the Veteran's daughter, L.K., as a helpless child on the basis of permanent incapacity for self-support prior to attaining age 18). In August 2010, the Veteran and his spouse testified at a Travel Board hearing before the undersigned Veterans Law Judge. In February 2017, the Board remanded the case to the Agency of Original Jurisdiction (AOJ) for further development to include an additional VA examination for hypertension to determine whether it was "at least as likely as not" directly incurred during service, to include as a result of the Veteran's presumed exposure to herbicide agents in Vietnam, and/or secondary to his service-connected diabetes mellitus, type II. Through the March 2017 and October 2017 medical opinions, the Board finds that with respect to the claim decided herein, the AOJ has complied with the February 2017 remand directives. Stegall v. West, 11 Vet. App. 268 (1998). Thus, the issue has been properly returned to the Board for appellate review. The issue of entitlement to recognition of L.K. as the "helpless child" of the Veteran on the basis of permanent incapacity for self-support prior to attaining age 18 is addressed in the REMAND portion of the decision below and is REMANDED to the AOJ. FINDING OF FACT The Veteran's hypertension did not have its onset during active service, was not caused by active service, to include his in-service herbicide exposure, and was not caused or aggravated by his service-connected diabetes mellitus type II. CONCLUSION OF LAW The criteria for service connection for hypertension, to include as secondary to the service-connected diabetes mellitus type II, have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110 (2012); 38 C.F.R. § 3.303 (a) (2017). "To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"- the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection for certain chronic diseases, including hypertension, may also be established based upon a legal "presumption" by showing that the disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1112, 1137 (2012); 38 C.F.R. §§ 3.307, 3.309 (2017). In addition, service connection may be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d) (2017). The Board observes that, with respect to the Veteran's National Guard service, the applicable laws and regulations permit service connection only for disability resulting from disease or injury incurred or aggravated while performing ACDUTRA, or injury incurred or aggravated while performing inactive duty for training (INACDUTRA). See 38 U.S.C. § 101(22), (24); 38 C.F.R. § 3.6. The Veteran contends that he developed hypertension as a result of his exposure to Agent Orange while serving in the Republic of Vietnam, and/or as secondary to his service-connected diabetes mellitus. The Board notes that the term hypertension refers to persistently high arterial blood pressure. Medical authorities have suggested various thresholds ranging from 140 mm. Hg systolic and from 90 mm. Hg diastolic. See Dorland's Illustrated Medical Dictionary 909 (31st ed. 2007). Similarly, for VA purposes, the term hypertension means that the diastolic blood pressure is predominantly 90 mm. or greater. The term isolated systolic hypertension means that the systolic blood pressure is predominantly 160 mm. or greater with a diastolic blood pressure of less than 90 mm. See 38 C.F.R. § 4.104, Code 7101, Note 1 (2017). Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310 (a) (2017). The secondary condition shall be considered a part of the original condition. Id. The phrase "due to or the result of" encompasses disability caused by or aggravated by the service-connected disease or injury. See Allen v. Brown, 7 Vet. App. 439 (1995). "Aggravation" of a nonservice-connected condition by a service-connected condition means a chronic worsening of the nonservice-connected condition by the service-connected condition, not merely temporary or intermittent flare-ups. See Hunt v. Derwinski, 1 Vet. App. 292 (1991); Davis v. Principi, 276 F.3d 1341 (Fed. Cir. 2002). Lastly, presumptive service connection is available on the basis of herbicide exposure for certain specified diseases manifested to a degree of 10 percent within a specified period in a Veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975. 38 U.S.C. § 1116 (a) (2012). If a Veteran was exposed to certain herbicide agents, such as those in "Agent Orange", during active military, naval, or air service, the following diseases shall be service connected if the requirements of 38 U.S.C. § 1116; 38 C.F.R. § 3.307 (a)(6)(iii) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 U.S.C. § 1113; 38 C.F.R. § 3.307 (d) are also satisfied: AL amyloidosis, chloracne or other acneform diseases consistent with chloracne, Type 2 diabetes mellitus, Hodgkin's disease, ischemic heart disease, all chronic B-cell leukemias, multiple myeloma, non-Hodgkin's lymphoma, Parkinson's disease, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), and soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309 (e). Notwithstanding the provisions of §§ 3.307, 3.309, if a claim fails to satisfy the criteria for service connection on a presumptive basis due to herbicide exposure, this fact does not preclude an appellant from establishing service connection with proof of actual direct causation. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Relevant to this case, the National Academy of Sciences (NAS) Institute of Medicine's Veterans and Agent Orange: Update 2010 (2010 Update) concluded that there is limited or suggestive evidence of an association between exposure to Agent Orange and hypertension. See Nat'l Acad. of Sci., Inst. of Med., Veterans & Agent Orange: Update 2010 (2011). The Secretary has discussed the 2006 and 2008 Updates-which contain the same analysis of hypertension as the 2010 Update-in the Federal Register. See e.g., 75 Fed. Reg. 32,540, 32,549 (June 8, 2010) ("In Update 2006, NAS concluded that there was 'limited or suggestive evidence of an association between exposure to the compounds of interest and hypertension.'"); 75 Fed. Reg. 81,332, 81,333 (noting that NAS, in 2008, categorized certain health outcomes, including hypertension, to have "'limited or suggestive evidence of an association. This category is defined to mean that evidence suggests an association between exposure to herbicides and the outcome, but a firm conclusion is limited because chance, bias, and confounding could not be ruled out with confidence."). The Veteran's service personnel records confirm that he had service in the Republic of Vietnam from March 1969 to March 1970. As such, exposure to herbicides is conceded. Turning to the service treatment records, the Board notes that the January 1967 pre-induction examination report reflects that the clinical evaluation of the heart and vascular system was normal, the Veteran's blood pressure reading was shown to be 130/76, and he denied a history of high or low blood pressure in his report of medical history. The August 1968 induction examination also reflects that the Veteran denied a history of high or low blood pressure. The remainder of the service treatment records is absent any indications of, or treatment for, elevated blood pressure, or symptoms referable to high blood pressure. At the March 1970 separation examination, the clinical evaluation of the heart and vascular system was shown to be normal, the Veteran had a blood pressure reading of 116/28, and he denied a history of high or low blood pressure in his medical history report. The medical evidence of record does not show that the Veteran sought treatment for hypertension immediately following his period of service or for several years thereafter. The record does not show that hypertension manifested within one year of separation from service. Therefore, the Board finds that hypertension did not manifest in service or within one year thereafter. The evidence also does not show that the Veteran sought treatment for hypertension until many years after service. Indeed, the earliest treatment report reflecting a clear diagnosis of hypertension was the September 2006 VA treatment report which reflects an assessment of hypertension that was well-controlled at the time. The Veteran was afforded a VA examination in connection to his hypertension claim in May 2009, during which time he reported that his hypertension had its onset sometime between 2007-2008, and he was found to have high blood pressure during a routine follow-up evaluation. The VA examiner noted that the Veteran required continuous medication to control his hypertension, and his symptoms had been stable since being placed on 40 milligrams of Lisinopril. On physical examination, the Veteran's blood pressure readings were shown to be 112/66, 120/70, and 114/72 mmHg. Based on his discussion with, as well as his evaluation of, the Veteran, the VA examiner diagnosed the Veteran with having essential hypertension. When asked whether the Veteran's essential hypertension was a complication of his diabetes, the examiner noted that it was not, and further noted that the Veteran's lab results showed no evidence of renal dysfunction. Treatment records issued from UAB Highlands medical facility reflect that the Veteran was hospitalized in March 2009 after experiencing a several-day history of urinary difficulty, and subjective fever and chills. The Veteran's blood pressure was shown to be 148/90, and he underwent a series of tests and evaluations during the course of his hospitalization. He was thereafter diagnosed with having pyelonephritis. During the September 2010 VA examination in connection to his diabetes mellitus, type II, the examiner noted that the Veteran had been diagnosed with having hypertension in 2007. The examiner acknowledged the Veteran's hypertension diagnosis but noted that this disorder was neither a complication of his diabetes mellitus, nor had it worsened or increased as a result of his diabetes mellitus. At the September 2010 examination in connection to his hypertension, it was noted that the Veteran required continuous medication for control of his hypertension. On physical examination, his blood pressure readings were shown to be 117/63, 122/70, and 107/59 mmHg. Based on the evaluation of the Veteran, the VA examiner diagnosed him with having essential hypertension and determined that this disorder did not effect his usual occupation or his day-to-day activities. Pursuant to the September 2012 Board remand, the Veteran was afforded another VA examination in connection to his hypertension claim in May 2014. After interviewing the Veteran regarding his medical history and reviewing his claims file, the VA examiner diagnosed him with having hypertension since 2006. On physical examination, the Veteran's blood pressure readings were shown to be 146/81, 121/79, and 130/82, with an average blood pressure reading of 132/80. The examiner did not address whether the Veteran's hypertension was related to his exposure to Agent Orange in service, and/or secondary to his diabetes mellitus, type II. However, during the portion of the examination in connection to the Veteran's diabetes mellitus, the examiner noted that the Veteran's peripheral neuropathy was a complication of his diabetes mellitus. When asked whether the Veteran had any other pertinent physical findings, complications, conditions, signs or symptoms related to his diabetes mellitus, the examiner marked that he did not. At the October 2015 VA examination in connection to the Veteran's diabetes mellitus, when asked about any complications associated with his diabetes mellitus, she (the examiner) noted that the Veteran had diabetic peripheral neuropathy, and further determined that the Veteran did not have any other pertinent physical findings, complications, conditions, signs and/or symptoms associated with his diabetes mellitus. However, neither the May 2014, nor the October 2015 VA examination provided an opinion as to whether the Veteran hypertension had its onset in service, and/or is secondary to his service-connected diabetes mellitus. Pursuant to the February 2017 remand, the Veteran was afforded another VA examination in March 2017, at which time, his blood pressure readings were shown to be 122/72, 128/70, and 122/70, and he was diagnosed with having hypertension. According to the VA examiner, the Veteran's hypertension was less likely than not incurred in, or caused by, an in-service injury, event or illness. In reaching this determination, the VA examiner noted that the Veteran was diagnosed with having hypertension in 2005, many years after his separation from service. The examiner also took into consideration the NAS report which documented and addressed the limited or suggestive link between hypertension to herbicide exposure. However, according to the examiner, the Veteran's hypertension is less likely than not due to his Agent Orange exposure or any other herbicide exposure. According to the examiner, with the exception of cancerous diseases, most conditions related to Agent Orange exposure initially manifest at the time of exposure rather than several years later. The examiner further reasoned that the Veteran possessed well-documented risk factors for the development of hypertension, which included the fact that he was an elderly African-American male. The examiner also determined that the Veteran's claimed hypertension is less likely than not proximately due to, or the result of, his service-connected diabetes mellitus. In reaching this determination, she (the examiner) observed no evidence of diabetic nephropathy in the Veteran's medical records, and noted that while the Veteran was treated for pyelonephritis at UAB Hospital in March 2009, he was treated without evidence of continued renal dysfunction. The VA examiner also took note of the Veteran's December 2016 lab test findings, and noted that his renal status was within normal limits as evidenced by these test results. The examiner also did not find that the Veteran's hypertension was aggravated beyond its natural progression or chronically worsened by his service-connected diabetes mellitus, noting that there was insufficient medical evidence in support of this theory. According to the VA examiner, the Veteran's hypertension "has followed the natural progression" and his blood pressure remained stable on a single antihypertensive agent. The Veteran underwent another VA examination which was conducted by a primary care physician in October 2017. After evaluating the Veteran, reviewing his claims file, to include all of his private treatment records issued from UAB Highlands hospital in 2009, and taking into consideration the NAS Updates with regard to Agent Orange exposure (which indicated that hypertension had been placed in the category of limited or suggestive evidence of association to exposure to Agent Orange), the VA examiner determined that the Veteran's hypertension is less likely than not incurred in or caused by an in-service injury, event or illness. In reaching this determination, the VA examiner took into consideration the Veteran's service treatment records which were negative for any signs of hypertension, and further noted that he was not diagnosed with having hypertension until 2005, many years after his separation from service. The VA examiner also found that the information in the NAS Updates did not reveal clear evidence for hypertension development due to Agent Orange exposure. According to the examiner, if this was the effect of herbicidal exposure, the disease will exhibit itself immediately, not several years after. The examiner also noted that the Veteran's body mass index (BMI) is in the 34 range, and commented that obesity is a major risk factor for hypertension and diabetes mellitus, type II. In addition, the VA examiner determined that the Veteran's hypertension is less likely than not proximately due to or the result of his service-connected diabetes mellitus. In reaching this determination, the examiner noted that the Veteran's diabetes and hypertension were diagnosed around the same year, and the Veteran's microalbumin level, which is an indicator of diabetic nephropathy, was normal in 2017, and therefore clear for signs of this disorder. The VA examiner also noted that the Veteran was obese at the time he was diagnosed with hypertension, and added that obesity is "the major risk factor in [the] development of [hypertension] and/or diabetes mellitus." The examiner also did not observe any signs of renal damage in the Veteran's treatment records during his March 2009 hospitalization for pyelonephritis, and further noted that the Veteran's urinalysis results throughout the years were negative for any signs of renal damage. The examiner observed only transient proteinuria in the Veteran's urinalysis findings, and noted that if the Veteran's hypertension was due to diabetes mellitus, these lab tests would have reflected signs of persistent proteinuria. Finally, the examiner also did not find that the Veteran's hypertension was aggravated beyond its normal progression, or chronically worsened, by his service-connected diabetes mellitus. In reaching this determination, the examiner noted that there was no evidence that the Veteran's diabetes mellitus worsened his hypertension, adding that his blood pressure reading is at goal with the use of his medications, and his renal function is shown to be normal. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for his hypertension. As noted above, the Veteran's service treatment records are negative for any treatment for, or diagnosis of hypertension, or signs or notations of elevated blood pressure readings, and there is no evidence that the first manifestation of his hypertension occurred within the first post-service year after the Veteran's discharge from service in March1970, nor has the Veteran so contended. As such, service connection on a presumptive basis is not warranted for this disability. The Veteran's service treatment records associated with his period of service in the U.S. Army National Guard of Alabama from August 1978 to August 1997 are also negative for signs of, or treatment for, elevated blood pressure, or symptoms referable to high blood pressure. With respect to presumptive service connection for chronic diseases as it pertains to any verified period of ACDUTRA, the United States Court of Appeals for Veterans Claims (Court) has held that a claimant whose claim is based on a period of ACDUTRA and INACDUTRA will not be entitled to the "presumption of service connection." See Smith v. Shinseki, 24 Vet. App. 40, 47 (2011). This is so because, by definition, the presumption of service connection applies where there is no evidence that a condition began in or was aggravated during the relevant period of service. By contrast, for a claimant whose claim is based on a period of ACDUTRA or INACDUTRA, there must be some evidence that the condition was incurred or aggravated during the relevant period of service. See Id. Thus, service connection is not warranted for hypertension on a presumptive basis pertaining to chronic diseases concerning any verified period of ACDUTRA. Indeed, the Board further observes that the post-service record on appeal is similarly negative for any diagnosis of hypertension until many years after his active service. In fact, the first post-service medical evidence of record reflecting a diagnosis of hypertension is the September 2006 VA treatment report which is dated more than thirty-six following his period of active service, and nine years after his period of service in the Army National Guard. In addition, there is nothing in the record to show that the Veteran's hypertension was incurred in service, and none of his treatment providers or VA examiners have found that his current hypertension was incurred in, or otherwise related to, his military service. Both the March 2017 and October 2017 VA examiners determined that based on a review of the available medical records and the Veteran's in-person medical history and physical examination, it was less likely than not that his claimed hypertension was incurred in or caused by an in-service event or illness. In reaching this conclusion, both examiners referenced the service treatment records which did not show any complaints or diagnosis of, or treatment for hypertension during his military service. Both these examiner also noted that the Veteran's hypertension was not diagnosed until 2005, which is thirty-five years after his separation from service. In addition, the examiners did not find there to be any connection or link between the Veteran's hypertension diagnosis and his military service. Both examiners acknowledged and reviewed the NAS Medical Updates which addressed the fact that there was limited/suggestive evidence of an association between hypertension and herbicide exposure. However, even taking the NAS reports into consideration, both examiner still found no clear evidence of hypertension development due to Agent Orange. Collectively, both the March 2017 and October 2017 VA examiners determined that other than cancerous diseases, the effect of herbicide exposure would manifest and exhibit itself immediately, not several years after. The March 2017 also attributed the Veteran's hypertension to certain risk factors, to include the fact that he was an elderly African-American male. The October 2017 VA examiner attributed the Veteran's hypertension to his obesity, noting that obesity was a major risk factor for hypertension. The Board also finds that the Veteran is not entitled to service connection for hypertension on a secondary basis because the most probative medical evidence of record, by way of the March 2017 and October 2017 opinions, has found that it is less likely than not that the hypertension was caused or aggravated by the service-connected diabetes mellitus. The content of the examination reports have been discussed and outlined above. The Board finds the opinions provided by these examiners to be well reasoned and supported by reference to objective medical evidence. In this regard, the Veteran's hypertension has been related to his obesity, as well as certain risk factors, to include his age and gender. Collectively, the medical opinions are based on a discussion with the Veteran regarding his medical history and current condition, a complete review of the medical records, and physical examinations. In addition, the VA medical opinions, in conjunction with one another, provided clear and detailed opinions addressing whether the Veteran's hypertension was related to his military service (to include his in-service herbicide exposure) and/or proximately due to, or aggravated beyond a natural progression, by his service-connected diabetes mellitus, type II, and provided well-supported rationales that relied not only on the objective medical findings within the record, but also referenced relevant medical principles that addressed the causes underlying, and risk factors of hypertension. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (which holds that factors for assessing the probative value of a medical opinion are the treatment provider's access to the claims file and the thoroughness and detail of the opinion.) The Board acknowledges the Veteran's contentions (by way of the January 2018 Written Brief Presentation) but finds that the October 2017 VA physician qualified as an "appropriate health professional" and had the requisite skill, knowledge and medical expertise to provide an opinion concerning the nature and etiology of the Veteran's hypertension. Further, and of particular significance to the Board in this matter, is the fact that no medical professional has provided any opinion indicating that the Veteran's hypertension is in any way related to his military service, and/or secondary to his service-connected diabetes mellitus, type II. Thus, the competent medical evidence of record reflects that the Veteran's hypertension is not related to his military service, and/or secondary to his service-connected diabetes mellitus, type II The Board acknowledges the Veteran's belief that his hypertension is related to his military service and/or his service-connected diabetes mellitus. The Board notes that the Veteran is competent to testify as to a condition within his knowledge and personal observation. See Barr v. Nicholson, 21 Vet. App. 303, 308-10 (2007). However, it is clear, based on a detailed review of the statements overall, that the Veteran has no actual specialized knowledge of medicine and that he is merely speculating as to whether his hypertension was incurred in service and/or related to his service-connected diabetes mellitus. In this regard, he is not competent to diagnose this condition or symptoms or relate such to his Agent Orange exposure, and/or his diabetes mellitus, as such diagnosis and relationship are complex questions the answers to which require specialized medical knowledge and specific testing. The cause of hypertension manifesting relatively long after the period of service and whether one disorder pertaining to an organ caused or chronically worsened a disability of another organ are complex questions, not simple ones, and, under the facts of this case, not questions that can be answered by observation with ones senses. Medical expertise is required to provide competent opinions with regard to these questions. As such, the Veteran's statements to this effect are lacking in probative value. For the reasons and bases discussed above, the Board finds that a preponderance of the evidence is against the claim for service connection for hypertension, to include as secondary to a service-connected disorder, and this claim must be denied. ORDER Entitlement to service connection for hypertension, to include as secondary to a service-connected disorder, is denied. REMAND Pursuant to the February 2017 decision, the Board remanded the Veteran's claim of entitlement to recognition of his daughter, L.K., as a helpless child on the basis of permanent incapacity for self-support prior to attaining age 18, for additional evidentiary development. Specifically, the Board noted that medical records pertaining to L.K.'s various disabilities, and treatment she received and underwent for these disabilities, remained outstanding. The Board instructed the AOJ to contact the Veteran and request that he provide and/or complete the necessary medical authorization forms in order for the AOJ to obtain all outstanding medical records for his daughter, L.K., to include medical records from the UAB Hospital, Children's Hospital Montclair East, and East Side Mental Health. The Veteran received and completed these medical release forms in March 2017. However, the forms contained the Veteran's wife's signature rather than his own signature. In March 2017, VA alerted the Appeals Management Center (AMC) that the private medical contractor had rejected the Veteran's medical records request due to an invalid signature. In a July 2017 letter, the AOJ notified the Veteran that the medical authorization forms he had submitted had been rejected due to the fact that the forms did not contain a valid signature. The Veteran was informed that these forms required his signature in order to be processed. The AOJ provided the Veteran with additional medical release forms, and in November 2017, the Veteran completed these forms and provided his own signature on these forms. However, in December 2017, VA once again alerted the AOJ that the medical records request had been rejected by the private medical contractor due to an invalid signature. Unfortunately, it does not appear that the AOJ has informed the Veteran that his medical records request has once again been rejected, and offered him the opportunity to retrieve and submit these records himself. Moreover, the Board is unclear as to why the Veteran's medical records request has been rejected given that the Veteran completed these forms appropriately and signed them himself in November 2017, pursuant to the instructions he was given by way of the July 2017 letter. As such, another attempt should also be made to obtain outstanding private medical records pertaining to treatment L.K. has received for her disabilities. VA has an obligation to make a reasonable effort to obtain identified private treatment records. See 38 C.F.R. § 3.159(c)(1). Accordingly, the case is REMANDED for the following action: 1. Send a letter to the Veteran, informing him as to the reason(s) why his November 2017 medical records request was rejected and provide clear instructions to the Veteran as to the information he must provide in order to retrieve these records. Provide the Veteran with additional medical release forms and ask him to provide the full address for the private treatment facility(ies) where his daughter, L.K. receives, and has received, treatment for any physical and mental disabilities. This includes the addresses for UAB Hospital, Children's Hospital Montclair East, and East Side Mental Health. After acquiring this information, instruct the Veteran to complete the release form authorizing VA to request L.K.'s private medical records from these above-referenced treatment providers. Direct the Veteran as to any necessary steps or instructions to ensure these forms are appropriately completed. After obtaining the appropriate release of information forms where necessary, procure and associate with the claims folder copies of records of any private treatment that the Veteran's daughter, L.K., has received from these treatment facilities. If any records are not obtained, or if the medical records request is rejected, inform the Veteran and provide him an opportunity to submit the records. All such available documents should be associated with the Veteran's claims folder. Any negative responses should be properly annotated into the record. 2. After completing the above, and undertaking any additional evidentiary development deemed necessary, readjudicate the remaining issue on appeal. If the benefit sought is not granted, the Veteran and his representative should be provided with a supplemental statement of the case. An appropriate period of time should be allowed for response before the case is returned to the Board. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ JAMES G. REINHART Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs