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
acute rheumatic fever
allergic contact dermatitis
conductive hearing loss
extrinsic allergic alveolitis
irritable bowel syndrome
irritant contact dermatitis
malignant melanoma of the skin
malignant neoplasm of bone and articular cartilage
malignant neoplasm of the bladder
malignant neoplasm of the liver
malignant neoplasm of the nasopharynx
malignant neoplasm of the renal pelvis and ureter
monoclonal gammopathy of undetermined significance (MGUS)
obstructive and reflux nephropathy
poisoning and toxic reaction from plants and fungi
rapidly progressive crescentic glomerulonephritis
renal artery atherosclerotic disease
renal stone disease
retinal vascular occlusive disease
rheumatic heart disease
Ross River virus infection
sensorineural hearing loss
spinal adhesive arachnoiditis
sprain and strain
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.