Citation Nr: 21030655
Decision Date: 05/19/21	Archive Date: 05/19/21

DOCKET NO. 16-45 581
DATE: May 19, 2021

REMANDED

Entitlement to service connection for residuals of a spinal injury is remanded.

REASONS FOR REMAND

The Veteran served on active duty from September 1969 through September 1973.

This case is before the Board of Veterans' Appeals (the Board) on appeal from an August 2014 rating decision of the Department of Veterans Affairs (VA). By a November 2018 Board decision, the matter was remanded for further development.

Unfortunately, another remand is needed to satisfy VA's duty to assist the Veteran in the development of his claim.38 C.F.R. § 3.159(c)(1).

By way of history, consultation with a private medical provider's records department to obtain records for Dr. J.H. at A.M. Hospital, indicated that the Veteran's request for private records for treatment during 1998 could not be fulfilled based on the dates he provided for treatment.

By an October 2019 report of general information, the Veteran indicated that he needed to correct the date of treatment for private Dr. J.H. The RO instructed him to submit another completed VA form 21  4142(a). And in November 2019 the Veteran submitted a corrected VA form 21  4142(a) for Dr. J.H., changing the date of treatment to Sepetember 2000. Review of the record indicates that the RO never sent out this revised release to A.M. Hospital to try and obtain the private treatment records with the corrected date of treatment.

The matter is REMANDED for the following action:

1. Obtain private treatment records identified by the Veteran in his November 2019 VA form 21  4142(a) for Dr. J.H. at A.M. Hospital reflecting treatment in September 2000. If on remand, the RO determines a more recently signed VA form 21  4142(a) is needed for these records, then asked the Veteran to complete one. Make two requests for the authorized records for Dr. J.H., unless it is clear after the first request that a second request would be futile. 

2. After completion of Directive No. 1 and, if and only if, additional private records are obtained from Dr. J. H., obtain an addendum opinion from an appropriate clinician as to whether the Veteran's residuals of a spinal injury are at least as likely as not related to service, including a back injury sustained aboard a service ship.

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Nathaniel J. Doan

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	AD

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.