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 infectious mononucleosis
acute myeloid leukaemia
acute pancreatitis
adhesive capsulitis of the shoulder
allergic contact dermatitis
angle-closure glaucoma
anosmia
aortic aneurysm
aplastic anaemia
asthma
atherosclerotic peripheral vascular disease
carotid arterial disease
chloracne
chronic multisymptom illness
chronic pancreatitis
chronic venous insufficiency of the lower limb
coeliac disease
conjunctivitis
deep vein thrombosis
dementia pugilistica
dengue fever
diabetes mellitus
endometriosis
extrinsic allergic alveolitis
haemochromatosis
inflammatory bowel disease
irritant contact dermatitis
malignant neoplasm of bone and articular cartilage
malignant neoplasm of the cervix
malignant neoplasm of the eye
malignant neoplasm of the liver
malignant neoplasm of the lung
malignant neoplasm of the nasopharynx
mesangial IgA glomerulonephritis
migraine
multiple sclerosis
non-aneurysmal aortic atherosclerotic disease
open-angle glaucoma
osteonecrosis, including dysbaric osteonecrosis
otitic barotrauma
otitis externa
patellar tendinopathy
pes planus
photocontact dermatitis
physical injury due to munitions discharge
polyarteritis nodosa
porphyria cutanea tarda
psoriasis
psoriatic arthropathy
pulmonary thromboembolism
renal artery atherosclerotic disease
retinal vascular occlusive disease
spinal adhesive arachnoiditis
sprain and strain
tinnitus
varicose veins of the lower limb
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.
