Citation Nr: 21014468 Decision Date: 03/12/21 Archive Date: 03/12/21 DOCKET NO. 16-11 195A DATE: March 12, 2021 REMANDED Entitlement to service connection for a back disability is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1953 to August 1955. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2014 rating decision by the Department of Veterans Affairs (VA). The Veteran was scheduled for a February 2020 Board hearing. However, the Veteran failed to appear for the hearing and to date the Veteran has not requested that the hearing be rescheduled. As such, the Veteran’s hearing request is withdrawn. 38 C.F.R. § 20.704(d). 1. Entitlement to service connection for a back disability is remanded. The Veteran contends that his back disability is related to service. Specifically, the Veteran expressed that during active duty, he was hospitalized for 28 days in Korea for a back injury. See VA Form 9. The Veteran stated that he was lifting a motor which was going to be rebuilt and ever since then, he has suffered from back pains. Id. On his VA Form 9, the Veteran indicated that treatment records from St. Lukes satellite clinic, VA Ponce outpatient clinic, and VAMC, San Juan should be requested. In addition, in January 2019, the Veteran submitted a signed VA Form 21-4142, Authorization to Disclose Information to the Department of Veterans Affairs, accompanied by a VA Form 21-4142a, General Release for Medical Provider Information. The Veteran reported receiving treatment from Dr. N.C. at Euripides Rubio Outpatient Clinic. However, the authorizations were rejected on the basis of a “Foreign Veteran Address” and noting that the request for these records must be worked via the traditional process. See February 2019 Medical Records Request Reject Notice from the VA Private Medical Records Retrieval (PMR) Center. The file contains no indication that the AOJ made any additional attempts to obtain these records. The Board notes that the Reject Notice did not state that the records were unavailable, only that the PMR Retrieval Program requires that the AOJ obtain the records “via the traditional process” by requesting and obtaining the records directly. Furthermore, because the Veteran has supplied the contact information, the Board finds that the AOJ failed to make reasonable efforts to obtain these medical records, and that remand is necessary to obtain them. Although VA’s duty to assist requires the AOJ to obtain these records, the Veteran is also free to obtain the records directly from these medical providers himself and submit them to the AOJ, if he believes it will speed up the process of obtaining them. Additionally, there may be missing service treatment records (STRs). The only STR associated with the file is a separation examination dated in August 1955. Furthermore, the Board notes that it appears the Veteran is in receipt of Social Security Administration (SSA) benefits. However, it does not appear these records have been obtained. Accordingly, upon remand, SSA records should be obtained. As a final matter, private treatment records dated in January 2019 show a diagnosis of disc disease. The Veteran contends that his back disability is related to lifting a motor in service. The Veteran has not been afforded a VA examination for his back pain. Thus, on remand, the Veteran should be scheduled for a VA back examination. The matters are REMANDED for the following action: 1. Obtain any and all outstanding, pertinent VA and/or private treatment records, to include treatment records from St. Lukes satellite clinic, VA Ponce outpatient clinic, VAMC, San Juan, and treatment records from Dr. N.C. at Euripides Rubio Outpatient Clinic. If needed, request a medical release authorization to attempt to obtain the Veteran’s private medical records relating to his back disability. If no records can be found, indicate whether the records do not exist and whether further efforts to obtain the records would be futile. 2. Take the proper steps to obtain all of the Veteran’s STRs related to his active duty service. All facilities where such records may be stored should be searched. If such records have been destroyed or are irretrievably lost, it must be so documented for the record, and the Veteran should be so notified. The scope of the search must be noted in the record. 3. Obtain and associate all records pertaining to the Veteran concerning a claim for disability benefits from the Social Security Administration, to include all evidence and copies of any disability determination. 4. Thereafter, the Veteran should be scheduled for an appropriate VA examination to determine the nature and etiology of any back disability, found to be present. The claims folder, including a copy of this REMAND should be made available and reviewed by the examiner. All indicated studies should be performed, and all findings should be reported in detail.  The examiner must opine as to whether it is at least as likely as not that the Veteran’s back disability began in service, was caused by service, or is otherwise etiologically related to the Veteran’s active duty service.  In addressing the Veteran’s back disability, the examiner must address the Veteran’s contention that his back disability is related to his military occupational specialty and his injury after lifting a motor. The examiner must consider the Veteran’s contention that he has had back pain continuously since service. (Continued on the next page)   The examiner is advised that the Veteran is competent to report symptoms, and his reports must be considered and discussed in formulating the requested opinions. If his reports are discounted, the examiner should provide an explanation for doing so.  A complete rationale for all opinions rendered must be provided. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M.D. 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.