Citation Nr: 21066399 Decision Date: 10/29/21 Archive Date: 10/29/21 DOCKET NO. 19-17 997 DATE: October 29, 2021 REMANDED Entitlement to an initial rating in excess of 70 percent for posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served from September 1972 to February 1975. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2018 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In October 2021, the Veteran presented testimony at a Board virtual hearing before the undersigned Veterans Law Judge. Entitlement to a disability rating in excess of 70 percent for PTSD is remanded. The Veteran testified at his October 2021 Board hearing that he suffers from memory loss, he could not recall when and where he recently received the treatment for his PTSD. He has been homeless and was no longer living with his spouse. However, it was stated that a letter should be sent to his spouse to identify any outstanding treatment records. Thus, the case must be remanded for the RO to obtain and associate with the claims file any outstanding pertinent treatment records. Additionally, VA's duty to assist includes the conduct of a thorough and comprehensive medical examination. Robinette v. Brown, 8 Vet. App. 69, 76 (1995). This includes providing a new medical examination when a veteran asserts or provides evidence that a disability has worsened, and the available evidence is too old for an adequate evaluation of the current condition. Engelmann v. Brown, 5 Vet. App. 281, 284 (1993); see also Caffrey v. Brown, 6 Vet. App. 377, 381 (1994) (finding that VA should have ordered a contemporaneous examination of veteran because a 23-month-old exam was too remote in time to adequately support the decision in an appeal for an increased rating). The Veteran last underwent a VA examination in May 2018 in conjunction with his claim for increased disability rating for PTSD. The Veteran, through his attorney, testified at the Board hearing that his current PTSD symptoms have worsened since his last VA examination, and now include gross impairment in thought process, inappropriate behavior, memory loss, and disorientation to time and space. Thus, an additional VA examination is required to provide a current picture of his service-connected disability, which concerns the issue currently on appeal. 38 C.F.R. §§ 3.326, 3.327. In this regard, the Veteran's attorney stated that because the Veteran is homeless, she should be given proper notice of any scheduled VA examination, to ensure the notification reaches the Veteran. The matter is REMANDED for the following actions: 1. Obtain and associate with the claims file any updated records from the VA Medical Center in Chicago, Illinois, and all associated outpatient clinics, dated from June 2017 to the present. All records and/or responses received should be associated with the claims file. 2. Contact the Veteran, his wife, and his attorney; and ask the Veteran's wife to identify any VA or private facilities where the Veteran has received mental health treatment since 2017. 3. Schedule the Veteran for a VA psychiatric examination to determine the current severity of his service-connected PTSD. Because the Veteran is homeless, provide the Veteran's attorney with a timely notification of the date, time, and location of any scheduled VA examination, including by mail, email, and telephonic notification. Additionally, undertake any other appropriate means to notify a homeless veteran of a scheduled VA examination, following specific procedures for contacting homeless veterans as set forth in 38 C.F.R. § 1.710. All efforts to notify the Veteran and his attorney of a scheduled VA examination must be documented in the claims file. The claims file must be provided to the examiner in conjunction with the examination. After a review of the evidence of record, the examiner must provide accurate and fully descriptive assessments of all psychiatric symptoms attributable to the service-connected PTSD, to include the frequency and severity, with consideration of the statements of the Veteran. (Continued on the next page) The opinion must be based on the review of the claims file, and a complete rationale must be provided for any opinions expressed. 4. After completing the above, readjudicate the claim. If the benefit sought on appeal remains denied, provide an additional supplemental statement of the case to the Veteran, and return the appeal to the Board for appellate review, after the Veteran and his representative have had an adequate opportunity to respond. L. CHU Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. J. In, Counsel 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.