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
acquired cataract
adjustment disorder
analgesic nephropathy
animal envenomation
arachnoid cyst
ascariasis
Barrett's oesophagus
benign neoplasm of the eye and adnexa
benign prostatic hyperplasia
bruxism
cholelithiasis
cirrhosis of the liver
clonorchiasis
complex regional pain syndrome
cut, stab, abrasion and laceration
discoid lupus erythematosus
distal biceps brachii tendinopathy
diverticular disease of the colon
eating disorder
female sexual dysfunction
fibromuscular dysplasia
ganglion
haemorrhoids
hepatitis B
hepatitis D
hookworm disease
hypertension
incisional hernia
ischaemic heart disease
loss of teeth
Lyme disease
malignant neoplasm of the brain
malignant neoplasm of the endometrium
malignant neoplasm of the oesophagus
malignant neoplasm of the urethra
myopia, hypermetropia and astigmatism
opisthorchiasis
optochiasmatic arachnoiditis
otosclerosis
Parkinson’s disease and secondary parkinsonism
peritoneal adhesions
polymyalgia rheumatica
presbyopia
pterygium
relapsing polychondritis
sarcoidosis
Scheuermann's disease
schizophrenia
smallpox
spasmodic torticollis
spondylolisthesis and spondylolysis
suicide and attempted suicide
systemic lupus erythematosus
traumatic brachial plexopathy
umbilical hernia
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.
