BVA9503386 DOCKET NO. 91-39 181 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in San Francisco, Caifornia THE ISSUES Entitlement to service connection for flat feet and for a lumbar spine disability. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for the residuals of a right wrist fracture. Entitlement to an increased evaluation for post-traumatic stress disorder, currently rated 10 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD Hilary L. Goodman, Counsel INTRODUCTION The veteran had active service from October 1967 to October 1970. This appeal arises from a May 1989 rating decision by the San Francisco, California, Regional Office (RO) which granted service connection for post-traumatic stress disorder and assigned a 10 percent disability evaluation, and denied service connection for flat feet. The same RO, in an August 1989 rating decision, denied service connection for a lumbar spine disability and, in a July 1990 rating decision, denied the veteran's request to reopen a claim of entitlement to service connection for the residuals of a right wrist fracture. The veteran, whose claims file was transferred to the Manila, Philippines, RO in April 1994, has raised the issues of service connection for the residuals of Agent Orange exposure and for the residuals of injuries under 38 U.S.C.A. § 1151 (West 1991). These issues have not been adjudicated and are referred to the originating agency for appropriate action. REMAND The veteran's claims, following review, were remanded by the Board of Veterans' Appeals (Board) in September 1992. The report of a June 1994 VA psychiatric examination provided limited findings relative to the veteran's post-traumatic stress disorder. The examiner did not provide a Global Assessment of Functioning (GAF) Score or otherwise indicate the degree to which the psychiatric disorder results in reduction in initiative, flexibility, efficiency and reliability levels. The Board also notes that, while a diagnosis of major depression was made, a specific conclusion as to the etiologic relationship between this disability and the veteran's post-traumatic stress disorder was not noted. It is herein noted that two requests were made for the veteran's Social Security records but that no response from the Social Security Administration is of record. In view of the foregoing, the Board finds that the issue of service connection for flat feet should be deferred and the remaining issues should be REMANDED to the originating agency for the following action: 1. The originating agency should request the veteran to identify all recent sources of medical treatment and to furnish signed authorizations for release to the VA of private medical records. The originating agency should obtain copies of medical records (not already in the claims file) from all sources he identifies. All documents obtained should be associated with the veteran's claims file. 2. The originating agency should request copies of all of the veteran's VA outpatient treatment records not already in the claims file as well as any inpatient treatment records from the VA medical facilities identified by the veteran. All documents obtained should be associated with the veteran's claims file. 3. The originating agency again should request, from the Social Security Administration, legible copies of those portions of the evidentiary record, including medical records and vocational reports, upon which the grant of disability benefits was based. If the veteran's records are unavailable, the Social Security Administration should be requested to so advise the VA by letter. All documents received should be associated with the veteran's claims file. 4. Following completion of the above development, the veteran should be scheduled for a VA psychiatric examination to determine the severity of the service- connected post-traumatic stress disorder. The examination should be performed in accordance with the VA Physician's Guide for Disability Evaluation Examinations. All indicated tests, including appropriate psychological studies, should be conducted. The claims file must be made available to and reviewed by the examiner prior to the evaluation. Based upon a review of the record and the examination, the physician must assign a GAF Score consistent with the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders, and explain what the assigned score represents. Any etiologic relationship between the service-connected post-traumatic stress disorder and major depression, if present, should be identified. A complete rationale for any opinion expressed must be provided. A legible report of the examination should be provided. 5. The veteran should also be scheduled for a VA orthopedic examination. The express purpose of this examination is determine the etiology of the veteran's lumbar spine and right wrist disabilities. All necessary test and studies should be accomplished. The examining physician, who is requested to provide a written opinion as to the etiology of the lumbar spine and right wrist disabilities, should be given access to the veteran's claims file for a sufficient period of time prior to the examination to allow for a complete review of the record. 6. When the above development has been completed the originating agency should adjudicate the issue of the veteran's entitlement to service connection for major depression as secondary to post-traumatic stress disorder. The originating agency should also readjudicate the veteran's entitlement to a rating in excess of 10 percent for post-traumatic stress disorder and the issues of service connection for a lumbar spine disability and whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for the residuals of a right wrist fracture. 7. If any of the determinations made remains unfavorable to the veteran, a supplemental statement of the case which provides a summary of the evidence received since the June 1994 supplemental statement of the case should be issued to the veteran and his representative. They should be given the appropriate period of time in which to respond. Thereafter, the case should be returned to the Board for further consideration, if in order. No action is required by the veteran until he receives further notice. The purpose of this REMAND is to obtain clarifying medical information and to afford the veteran due process. WAYNE M. BRAEUER 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 determination. 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 remand 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) (1994).