(

a) Notwithstanding any other law, a person shall not be eligible to provide or receive payment for providing supportive services for years following a conviction for, or incarceration following a conviction for, fraud against a government health care or supportive services program, including Medicare, Medicaid, or services provided under Title V, Title XX, or Title XXI of the federal Social Security Act or a violation of subdivision (

a) of

Section 273a of the Penal Code, or

Section of the Penal Code, or similar violations in another jurisdiction. The department and the State Department of Health Care Services shall develop a provider enrollment form that each person seeking to provide supportive services shall complete, sign under penalty of perjury, and submit to the county. Submission of the form shall include the photocopying by the county of original documentation verifying the provider’s identity, and shall be considered as an application to render services under the Medi-Cal program consistent with subdivision (

c) of

Section 14043.1. A provider shall submit the form to the county in person, and the county shall retain the form and a copy of the identification documentation in the file of the provider. The form shall contain statements to the following effect:

(1) A person who, in the last years, has been convicted for, or incarcerated following conviction for, fraud against a government health care or supportive services program is not eligible to be enrolled as a provider or to receive payment for providing supportive services.

(2) An individual who, in the last years, has been convicted for, or incarcerated following conviction for, a violation of subdivision (

a) of

Section 273a of the Penal Code or

Section of the Penal Code, or similar violations in another jurisdiction, is not eligible to be enrolled as a provider or to receive payment for providing supportive services.

(3) A statement declaring that the person has not, in the last years, been convicted or incarcerated following conviction for a crime involving fraud against a government health care or supportive services program.

(4) A statement declaring that he or she has not, in the last years, been convicted for, or incarcerated following conviction for, a violation of subdivision (

a) of

Section 273a of the Penal Code or

Section of the Penal Code, or similar violations in another jurisdiction.

(5) The person agrees to reimburse the state for any overpayment paid to the person as determined in accordance with

Section 12305.83, and that the amount of any overpayment, individually or in the aggregate, may be deducted from any future warrant to that person for services provided to any recipient of supportive services, as authorized in

Section 12305.83. (

b) The department shall include the text of subdivision (

a) of

Section 273a of the Penal Code and

Section of the Penal Code on the provider enrollment form. (

c) A public authority or nonprofit consortium that is notified by the department or the State Department of Health Care Services that a supportive services provider is ineligible to receive payments under this

chapter or under Medi-Cal law shall exclude that provider from its registry. (

d) A public authority or nonprofit consortium that determines that a registry provider is not eligible to provide supportive services based on the requirements of subdivision (

a) shall report that finding to the department.