; (B) such item or service is not payable or available under this Act; and (C) the provider receives— (i) no reimbursement under this Act directly or indirectly for such item or service, and (ii) receives no amount for such item or service from an organization which receives reimbursement for such items or service under this Act directly or indirectly. (3) Contract requirements Any contract to provide items and services described in paragraph (2) shall— (A) be in writing and signed by the individual (or authorized representative of the individual) receiving the item or service before the item or service is furnished pursuant to the contract; (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) agrees not to submit a claim (or to request that the provider submit a claim) under this Act for such items or services; (ii) 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; (iii) acknowledges that no limits under this Act apply to amounts that may be charged for such items or services; and (iv) acknowledges that the provider is providing services outside the scope of the program under this Act. (4) Affidavit A participating provider who enters into a contract described in paragraph (2) 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 noncovered item or service, and be signed by such provider; (B) state that the provider will not submit any claim under this Act for any noncovered item or service provided to any individual enrolled under this Act