Fields marked with an asterisk (* ) are required.
It is recommended that you read the RMA Submission Guidelines before making your submission.
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)
Street
Suburb
State
Postcode
Telephone (business hours)
Telephone (after hours)
Email address
The condition under investigation or review
acute stress disorder
albinism
allergic rhinitis
alpha-1 antitrypsin deficiency
anxiety disorder
atrial fibrillation and atrial flutter
autosomal dominant polycystic kidney disease
cervical spondylosis
Charcot-Marie-Tooth disease
chronic myeloid leukaemia
chronic obstructive pulmonary disease
decompression sickness
diaphragmatic hernia
epicondylitis
Gaucher's disease
gingivitis
haemophilia
herpes zoster
Hodgkin's lymphoma
horseshoe kidney
Huntington's chorea
intervertebral disc prolapse
leptospirosis
lumbar spondylosis
malignant neoplasm of the breast
malignant neoplasm of the lung
malignant neoplasm of the prostate
malignant neoplasm of the salivary gland
malignant neoplasm of the small intestine
malignant neoplasm of the stomach
malignant neoplasm of the testis and paratesticular tissues
malignant neoplasm of unknown primary site
Marfan syndrome
melioidosis
mitral valve prolapse
multiple osteochondromatosis
neoplasm of the pituitary gland
osteogenesis imperfecta
osteomyelitis
osteoporosis
Paget's disease of bone
periodic limb movement disorder
peripheral neuropathy
plantar fasciitis
pleural plaque
portal vein thrombosis
posttraumatic stress disorder
pulmonary barotrauma
restless legs syndrome
rotator cuff syndrome
seborrhoeic keratosis
shin splints
soft tissue sarcoma
thoracic spondylosis
tinea
trochanteric bursitis and gluteal tendinopathy
vascular dementia
von Willebrand's disease
warts
Wilson's disease
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).
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.
