BVA9503489 DOCKET NO. 93-12 334 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for a psychiatric disorder. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. Horrigan, Counsel INTRODUCTION The veteran served on active duty from December 1960 to December 1962. Service connection for a psychiatric disorder was previously denied by the Board of Veterans' Appeals (Board) in decisions of January 1983 and July 1988. This matter came before the Board from a June 1992 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida, which held that the veteran had submitted new and material evidence to reopen his claim for service connection for a psychiatric disorder but that the evidence did not warrant allowance of the claim for service connection for this disability. The case is before the Board for appellate consideration at this time. REMAND The record contains a letter from a private psychiatrist, dated in April 1992, in which he stated, essentially, that he had made a partial review of the veteran's service records and believed that the veteran's erratic service performance ratings, behavioral changes, and conduct, including alcohol abuse, fighting, and general loss of control, were early symptoms of a bipolar disorder which was present during service. It appears that the physician reviewed documents from the veteran's service personnel folder which are not currently on file. It also appears that he possibly reviewed service medical records which are not currently in the claims folder. In addition, this physician requested an opportunity to review the record of all the veteran's inservice medical and psychiatric treatment as well as records of any disciplinary actions taken against him during active duty so that his actions could be assessed as they relate to mental illness. A review of the subsequent record indicates that the physician was at least provided with a copy of the veteran's available service medical records and that he would submit a further statement in regard to the veteran's claim. However, no additional statement from this physician is of record. Also, aside from three discharge summaries from a private hospital, no clinical records from this physician are in the claims folder. Review of the record further reveals that other relevant medical evidence may be available which is not currently in the claims folder. In view of the foregoing and given the duty to assist the veteran in the development of his claim under the provisions of 38 U.S.C.A. 5107(a) (West 1991), this case is remanded to the RO for the following actions: 1. The RO should contact the service department and request a search for additional service medical records, especially any documentation regarding a hospitalization at the U.S. Naval Hospital in San Diego during 1961, as well as documentation from the veteran's personnel file, including copies of records of all disciplinary actions and performance evaluations, as well as any psychiatric and/or psychological evaluations conducted in connection thereto. 2. The RO should contact the veteran and request that he provide the names, addresses, and approximate dates of treatment of all VA and non-VA health care providers who have treated him at any time since discharge from service for psychiatric symptoms. When the requested information and any necessary authori- zations have been obtained, the RO should attempt to obtain copies of all indicated records which are not currently in the claims folder. These records should include documentation from the VA medical facilities in Phoenix and Tucson, Arizona; Biloxi and Gulfport, Mississippi; Houston, Texas; and Fort Lyons, Colorado; as well as records from the Mental Health Bureau, the Maricopa County Mental Health Clinic, and the Arizona State Hospital, all in Phoenix, Arizona; the Escambia Community Mental Health Center in Pensacola, Florida; the Pensacola Mental Health Center; the Chattahoochee State hospital in Florida; the Baptist Hospital in Pensacola, Florida; Paul A. Johnson, M.D., of Phoenix, Arizona; and Lawrence E. Mobley, M.D., of Pensacola, Florida. Dr. Lawrence should also be requested to submit copies of all service records in his possession at the time of his April 1992 letter to the VA. and he should be invited to make any further comments deemed appropriate regarding the veteran claim. All documentation obtained should be associated with the claims folder. 3. Then, the veteran should be afforded a VA psychiatric examination to determine the nature, severity, and etiology of his psychiatric disorder. All pertinent special studies should be performed and all clinical findings reported in detail. The claims folder must be made available to the examiner prior to the evaluation so that he may study the clinical record in detail. At the conclusion of the evaluation, the examiner should express his medical opinion as to the degree of probability that the veteran's current psychiatric disability is a maturation of any psychiatric symptomatology noted in service. Also, based on a review of the record and the examination findings, the examiner should provide a Global Assessment of Function (GAF) Score indicating the level of impairment produced by any psychiatric disorder found. It is imperative that the examiners provide a definition of the GAF Score. 4. Then, after conducting any further development deemed appropriate, the RO should again adjudicate the veteran's claim. If the benefit sought on appeal remains denied, he and his representative should be provided with a Supplemental Statement of the Case and afforded a reasonable opportunity to respond. Thereafter, the case should be returned to the Board for further consideration, if appropriate. By this remand, the Board intimates no opinion as to the outcome warranted in this case. No action is required of the veteran until he is so informed by the RO. GARY L. GICK Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a deter- mination. This proceeding has been assigned to an individual member of the Board. Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. This action has been taken in accordance with the Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 303, 108 Stat. 4645, ___ (1994), and is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1993).