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 lymphoblastic leukaemia/lymphoblastic lymphoma
allergic rhinitis
ankylosing spondylitis
anosmia
aortic aneurysm and aortic wall disorders
aortic stenosis
asthma
carotid artery disease
chronic fatigue syndrome
chronic myeloid leukaemia
chronic pancreatitis
chronic solvent encephalopathy
colorectal adenoma
deep vein thrombosis
dermatomyositis
diabetes mellitus
eosinophilic oesophagitis
epilepsy
epileptic seizure
erectile dysfunction
fibromyalgia
gender dysphoria
giant cell arteritis
gingivitis
goitre
Graves' disease
Hashimoto's thyroiditis
heart block
heat stroke
hypertension
hyperthyroidism and thyrotoxicosis
hypogonadism
hypopituitarism
hypothyroidism
inflammatory bowel disease
malignant neoplasm of the anus and anal canal
malignant neoplasm of the cervix
malignant neoplasm of the colorectum
malignant neoplasm of the kidney
malignant neoplasm of the larynx
morbid obesity
motor neurone disease
narcolepsy
non-aneurysmal aortic atherosclerotic disease
periodic limb movement disorder
periodontal abscess
periodontitis
peripheral artery disease
pilonidal sinus
portal vein thrombosis
psoriasis
pulmonary thromboembolism
renal artery atherosclerotic disease
restless legs syndrome
retinal vascular occlusion
sensorineural hearing loss
sick sinus syndrome
sleep apnoea
somatic symptom disorder
steatohepatitis
sudden unexplained death
thoracic outlet syndrome
thrombosis with thrombocytopenia syndrome
tinnitus
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.
