Citation Nr: 21061449 Decision Date: 10/04/21 Archive Date: 10/04/21 DOCKET NO. 18-07 820 DATE: October 4, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is remanded. REASONS FOR REMAND The Veteran had active duty from September 1992 to September 1996. This matter is on appeal from a March 2016 rating decision. The Veteran had a hearing before the undersigned Veterans Law Judge in January 2021. In May 2021, the Board remanded this matter for additional development. 1. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD, is remanded. As noted in the prior Remand, the Veteran has claimed to have PTSD due to military sexual trauma and witnessing a helicopter crash and other crashes. In an April 2008 lay statement, he also claimed depression secondary to his nonservice-connected back pain. In another April 2008 lay statement, he reported having a panic disorder due to his stressful job in service and witnessing aircraft mishaps/crashes. The Board previously remanded, in part, to obtain a new VA examination, which was obtained in July 2021. That VA examiner noted he was unable to find any records from D.A., DO in the claims file to review. Such records, however, are in the claims file, specifically in the Social Security Administration (SSA) records from the Hospital Sisters Health System Oakleaf Pine Grove Family Medicine. D.A., DO is a provider at the same facility as R.D., DO. As such, an addendum VA medical opinion should be obtained to allow for the review of all pertinent medical records. The Board also requested that the Agency of Original Jurisdiction (AOJ) obtain private medical records. In May 2021, the AOJ requested such records from the Veteran, but he did not fully respond to the request for information. As this matter is being remanded, the AOJ should give the Veteran another opportunity to provide private medical records from Clearwater Counseling and any other relevant private medical provider whose records have not already been obtained. The matters are REMANDED for the following actions: 1. Ask the Veteran to complete a VA Form 21-4142 for Clearwater Counseling and any other relevant private medical provider(s). Make two requests for the authorized records from identified provider(s), unless it is clear after the first request that a second request would be futile. 2. After the above development has been accomplished, obtain an addendum medical opinion from the July 2021 VA examiner to consider any newly associated medical evidence (and the records of D.A., DO noted in the Remand above). If the July 2021 VA examiner is not available, a new VA medical opinion should be obtained. If a new VA examination is deemed necessary to provide an opinion, one should be provided. The VA medical opinion provider should determine the nature and etiology of any posttraumatic stress disorder (PTSD). If the Veteran is diagnosed with PTSD, the examiner must explain how the diagnostic criteria are met and opine whether it is at least as likely as not related to a verified in-service stressor. The Board notes that the Veteran's witnessing of a helicopter crash has been conceded. The examiner must opine whether the evidence of record, including the Veteran's lay statements, and the Veteran's service records, corroborate the claim that a personal assault occurred in service (38C.F.R. §3.304(f)(5)). If the examiner finds that evidence indicates that a personal assault occurred during the Veteran's active service, the examiner must opine whether any PTSD is at least as likely as not related to the in-service personal assault. If any other acquired psychiatric disorders are diagnosed, the examiner must opine whether each diagnosed disorder is at least as likely as not related to an in-service injury, event, or disease, to include the Veteran's April 2008 reports of depression secondary to his nonservice-connected back pain and a panic disorder due to his stressful job in service and witnessing aircraft mishaps/crashes. To the extent possible, the VA examiner should reconcile his/her findings with any conflicting findings regarding diagnosis. A fully articulated medical rationale for any opinion expressed must be set forth in the medical report. The VA medical opinion provider should discuss the particulars of this Veteran's medical history (to include consideration of past medical treatment, such as (a) service treatment records, (b) VA medical records, (c) prior VA examinations, and private medical records from (d) Pine Grove Family Practice, (e) Omne Clinic, (f) the Vet Center, and (g) any other records associated). The VA examiner should also consider the Veteran's lay statements [including but not limited to statements from April 2008 (receive in May 2008) and July 2015, and the January 2021 Board hearing testimony] and relevant medical science as applicable to this case, which may reasonably explain the medical guidance in the study of this case H.M. WALKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Lindio The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.