Citation Nr: 25005148 Decision Date: 04/16/25 Archive Date: 04/16/25 DOCKET NO. 17-21 801 DATE: April 16, 2025 REMANDED Service connection for headaches is remanded. Service connection for a back condition is remanded. Service connection for a neck condition is remanded. Service connection for a left shoulder condition is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1972 to April 1975. This matter comes before the Board of Veterans' Appeals (Board) from June 2015 and May 2017 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). In October 2019 and December 2023, the Veteran testified before the undersigned Veterans Law Judge. Transcripts are of record. This matter was previously before the Board in August 2020 and March 2021. In March 2021, the Board denied this matter. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (the Court). In a September 2022 memorandum decision, the Court vacated the March 2021 Board decision and remanded this matter for further development. In March 2023, the Board remanded this matter for further development consistent with the September 2022 memorandum decision. In February 2024, the Board denied this matter. The Veteran appealed the February 2024 Board decision to the Court. In a December 2024 Joint Motion for Remand, the Court vacated the February 2024 Board decision and remanded this matter for readjudication. 1. Service connection for headaches is remanded. 2. Service connection for a back condition is remanded. 3. Service connection for a neck condition is remanded. 4. Service connection for a left shoulder condition is remanded. In the December 2024 Joint Motion for Remand, the Court indicated the Board failed to adequately address whether VA made reasonable efforts to obtain missing medical records from DCH Regional Hospital in Tuscaloosa via the "PMR Vault." The Board finds that additional development effort is necessary, as reflected by the following summary of the prior development efforts. In October 2019, the Veteran submitted a VA Form 21-4142 identifying treatment from January 1977 to December 1981. In October 2019, the RO notified the Veteran that copies of his private medical records were requested from DCH Regional Medical Center. An October 2019 VA Form 21-0820 indicates that the RO faxed the request form on October 14, 2019, and on October 22, 2019. The October 2019 VA Form 21-0820 further indicates that the retrieval action was complete due to an "electronic correspondence received from the provider." The electronic correspondence received from DCH Regional Medical Center indicates that no records were found. A January 2020 confirmation sheet appears to indicate that files concerning DCH Regional Medical Center were uploaded to DOMA Technologies PMR Vault. A January 2020 Medical Records Request Reject Notice indicates that the request did not meet the criteria for action under the PMR Program Guideline as the identified records were an "exact duplicate" of a prior request. The VA Form 21-4142a attached to the reject notice was a copy of the Veteran's previously completed authorization form and identified treatment at DCH Regional Medical Center from January 1977 to December 1981. In April 2023 the RO sent the Veteran correspondence informing him that the Board had remanded his appeal in March 2023 with instructions for them to request records from of his treatment from the DCH Regional Hospital in Tuscaloosa, Alabama. The Veteran thereafter submitted an additional VA Form 21-4142 indicating treatment at DCH Regional Medical Center from August 1975 to April 1976. In a subsequent April 2023 VA Form 21-4138, regarding the DCH Health System, the Veteran indicated that all records from "20yrs, 10yrs back" were "purged" and are "no longer available." He also submitted an April 2023 correspondence from DCH Health System, which indicates there are "no records for specified date" and "1975-1976 purged." An April 2023 Medical Records Request Reject Notice indicates the request did not meet the criteria under the PMR Program Guideline because the request did not "provide complete private health providers (PHP) information." The VA Form 21-4142 attached to the rejection notice was a copy of the Veteran's April 2023 authorization form wherein he identified treatment from DCH Regional Medical Center from August 1975 to April 1976. Notably, during his December 2023 hearing before the undersigned, the Veteran testified that the DCH records were no longer available. Based on the Board's review, and due to the January 2020 confirmation sheet, which appears to indicate files concerning DCH Regional Medical Center were successfully uploaded to DOMA Technologies PMR Vault, it is not clear whether the requested records are not in existence or if the proper procedure to associate them with the claims file was not followed. The RO did not issue a formal finding notifying the Veteran of the unavailability of these records. Thus, remand is necessary to ensure substantial compliance with its prior remand instructions. The matters are REMANDED for the following action: Take the necessary steps to associate the Veteran's treatment records from the DCH Regional Hospital in Tuscaloosa, Alabama from the PMR Vault with the record. [The RO's attention is directed to the January 2020 confirmation page from the PMR Vault showing a successful file upload, which appears to indicate that files concerning DCH Regional Medical Center were in fact uploaded to DOMA Technologies PMR Vault.] If appropriate, ask the Veteran to complete a VA Form 21-4142 for DCH Regional Hospital in Tuscaloosa, Alabama and make two requests for the authorized records from DCH Regional Hospital in Tuscaloosa, Alabama, unless it is clear after the first request that a second request would be futile. (Continued on the next page) ? If the records are unavailable and it is determined that further efforts would be futile, issue a Formal Finding outlining the steps taken to assist the Veteran and notify the Veteran and his representative of the development efforts in accordance with 38 C.F.R. § 3.159(e). D. JOHNSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Aoughsten, 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.