Citation Nr: 21027807 Decision Date: 05/06/21 Archive Date: 05/06/21 DOCKET NO. 17-38 671 DATE: May 6, 2021 REMANDED The issue of entitlement to an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran had active duty in the United States Marine Corps (USMC) from October 2005 to October 2009 including service in Iraq. This matter comes before the Board of Veterans' Appeals (Board) from a July 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) which denied, in pertinent part, a claim of service connection for acquired chronic mental health condition to include PTSD. The Veteran submitted a Notice of Disagreement (NOD) in March 2017 and a Statement of the Case (SOC) was issued in June 2017. The Veteran perfected an appeal by submitting a timely VA Form 9 in July 2017. The Veteran and his representative appeared in a March 2021 hearing. A transcript of that hearing has been associated with the record. Entitlement to an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) VA Medical Center treatment records from Phoenix show that the Veteran complained of PTSD related symptoms in April 2015. In December 2016, the Veteran's PTSD Checklist score was 70 out of 80. Treatment records from February 2017 show that the Veteran received PTSD treatment at a Vet Center. There is, however, no record of the Veteran's PTSD treatment associated with the Veteran's file. Given the evidence of record, the Board finds that VA has a duty to assist the Veteran in obtaining PTSD treatment records at the Vet Center. VA's duty to assist includes making reasonable efforts to obtain relevant records from Federal departments or agencies that have been adequately identified by the claimant. 38 U.S.C. § 5103A(c)(1); 38 C.F.R. § 3.159(c)(2)-(3). Given the Veteran's testimony that he received treatment at the Vet Center that are corroborated by contemporaneous VA Medical Center treatment records, additional efforts are needed. Although the June 2016 VA examiner opined that the Veteran did not meet the DSM-V criteria for PTSD, the opinion was based on the facts available to the examiner at the time. As discussed above, since the June 2016 VA examination, the Veteran has received PTSD treatment at a Vet Center. In effect, the June 2016 VA examination was based on incomplete facts and a contradictory medical opinion was added. There is, however, still no medical evidence of record of the Veteran being diagnosed as having PTSD under DSM-V criteria. Therefore, a new examination is required to clarify the nature and etiology of the Veteran's acquired psychiatric disability based on the entirety of the Veteran's file. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); see also Colvin v. Derwinski, 1 Vet. App. 171, 174 (1991) (Board may not make independent medical assessments). The matter is REMANDED for the following action: 1. Undertake additional efforts to associate all evidence with the claims file, to include the missing PTSD treatment at a "Phoenix Vet Center" and any other evidence missing from the electronic claims file. Document all such efforts in the claims file. 2. Schedule the Veteran for an examination by a VA clinician to determine the nature and etiology of the Veteran's acquired psychiatric disorders, to include claimed PTSD. The clinician should review the virtual file. The clinician is to address the following: (a.) State whether PTSD, or any other acquired psychiatric disability, is currently present. If the examiner disagrees with a diagnosis already established in the medical records, such as the VA Medical Center treatment records, Vet Center records, or the June 2016 VA examination, he/she should so state and explain why. (b.) Whether it is at least as likely as not (50 percent or greater probability) that any acquired psychiatric disability, if diagnosed, manifested during or is otherwise caused by the Veteran's period of active service including the Veteran's reported events or fear of attack in Iraq. J.W. FRANCIS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board H. Yun, Associate 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.