Fields marked with an asterisk (
*) are required.
It is recommended that you read the
RMA Submission Guidelines before making your submission. Your details
Name of person making the submission
Position of person making the submission (if applicable)
Name of organisation on behalf of whom the submission is made (if applicable)
Your address for correspondence
Telephone (business hours)
Telephone (after hours)
The condition under investigation or review
carpal tunnel syndrome
chronic fatigue syndrome
chronic gastritis and chronic gastropathy
chronic solvent encephalopathy
dental pulp and apical disease
familial adenomatous polyposis
fibrosing interstitial lung disease
gastro-oesophageal reflux disease
hyperthyroidism and thyrotoxicosis
ischaemic heart disease
malignant neoplasm of the anus and anal canal
malignant neoplasm of the breast
malignant neoplasm of the colorectum
malignant neoplasm of the larynx
malignant neoplasm of the oral cavity, oropharynx and hypopharynx
malignant neoplasm of the pancreas
mesangial IgA glomerulonephritis
motor neurone disease
porphyria cutanea tarda
sick sinus syndrome
sudden unexplained death
Date of notification
In the space provided below, please detail the submission you consider to make for the RMA's
consideration. If you have prepared a submission in a digital form able to be uploaded
(.doc, .docx or .pdf), you have the option of including it as an attachment below.
Attach any documents relevant to your submission using the fields below (.doc, .docx or .pdf).
Disclosure of information
Under section 196K of the VEA, certain decisions made by the Authority are reviewable by the
Specialist Medical Review Council (SMRC). If a valid application for review by the SMRC is made,
the VEA requires the Authority to disclose to the SMRC all information relevant to its determination
or decision. This includes applications for investigation or review, and submissions received
relevant to the matter being review by the SMRC.
I have read and understood the above disclosure of information statement.
Once you have completed your submission, the information will be available in a PDF format
for you to save (or print out) for your records.