; (B) not be entered into at a time when the individual is facing an emergency health care situation; and (C) clearly indicate to the individual receiving such items and services that by signing such a contract the individual— (i) acknowledges that the individual has the right to have such items or services provided by other providers for whom payment would be made under this Act; (ii) agrees not to submit a claim (or to request that the provider submit a claim) under this Act for such items or services even if such items or services are otherwise covered by this Act; (iii) agrees to be responsible for payment of such items or services and understands that no reimbursement will be provided under this Act for such items or services; (iv) acknowledges that no limits under this Act apply to amounts that may be charged for such items or services; and (v) acknowledges that the provider is providing services outside the scope of the program under this Act. (3) Affidavit A provider who enters into a contract described in paragraph (1) shall have in effect during the period any item or service is to be provided pursuant to the contract an affidavit that shall— (A) identify the provider who is to furnish such covered item or service, and be signed by such provider; (B) state that the provider will not submit any claim under this Act for any covered item or service provided to any individual enrolled under this Act during the 2-year period beginning on the date the affidavit is signed; and (C) be filed with the Secretary no later than 10 days after the first contract to which such affidavit applies is entered into. (4) Enforcement If a provider signing an affidavit described in paragraph (3) knowingly and willfully submits a claim under this title for any item or service provided or receives any reimbursement or amount for any such item or service provided pursuant to a private contract described in paragraph (1) with respect to such affidavit— (A) any contract described in paragraph (1) shall be null and void