Citation Nr: 21023868 Decision Date: 04/21/21 Archive Date: 04/21/21 DOCKET NO. 18-53 310A DATE: April 21, 2021 REMANDED Entitlement to an initial disability rating in excess of 50 percent for the Veteran's service-connected post-traumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from December 1952 to December 1955. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2018 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). When this case was last before the Board in March 2020, it was remanded for additional development. Specifically, the RO was instructed to obtain any outstanding VA treatment records and to obtain an examination regarding the current severity of the Veteran’s service-connected PTSD. The Veteran’s VA treatment records were obtained, and the Veteran was afforded an appropriate examination. As such, the Board finds that the AOJ substantially complied with the directives in the March 2020 remand. See Stegall v. West, 11 Vet. App. 268, 271 (1998). PTSD The Board notes that the record for review may be incomplete. In September 2019 the Veteran submitted a VA Form 21-4142 Authorization for Release of Information to the VA. This form authorized the VA to obtain records from a Dr. J.T. from 2001 to present. However, these treatment records are not in the claims file, and the RO must attempt to obtain them. When requesting records not in the custody of a Federal department or agency, such as private treatment records, the RO must make an initial request for the records and at least one follow-up request if the records are not received or a response that records do not exist is not received. In October 2019, the RO sent the Veteran notice that they made one attempt to obtain the Veteran’s private treatment records on September 26, 2019. However, no second attempt was made or documented. As such, a remand is required in order to make a second attempt to obtain the Veteran’s treatment records which may be relevant to his claim on appeal. Additionally, the Board reminds the Veteran that the duty to assist is not a one-way street. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Therefore, it is incumbent upon him to cooperate with the VA in developing his claims, consistent with the directives discussed below. The matters are REMANDED for the following action: Undertake the appropriate development and make efforts to obtain all outstanding medical records in accordance with the duties set forth in 38 C.F.R. § 3.159(c). Additionally, the RO must contact the Veteran and afford him the opportunity to identify or submit any additional pertinent evidence in support of the issue on appeal. Based on his response, the RO must attempt to procure copies of all records which have not previously been obtained from identified treatment sources. All attempts to secure this evidence must be documented in the claim file by the RO. If, after making reasonable efforts to obtain named records the RO is unable to secure the same, the RO must notify the Veteran and (a) identify the specific records the RO is unable to obtain; (b) briefly explain the efforts that the RO made to obtain those records; (c) describe any further action to be taken by the RO with respect to the claim; and (d) that he is ultimately responsible for providing the evidence. The Veteran must then be given an opportunity to respond. T. REYNOLDS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Gresham 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.